Comprehensive analysis of clinical features, electrocardiogram, and imaging in de Winter syndrome

This study summarizes the clinical characteristics, disease progression, risk factors, electrocardiogram (ECG), and imaging features, and early intervention strategies for patients with de Winter syndrome. It aims to improve understanding and early recognition of this syndrome among clinicians, especially in emergency departments, to ultimately reduce patient mortality.

The study cohort comprised 105 patients. Thirteen hospitalized cases were diagnosed with de Winter syndrome at Hainan General Hospital from January 2018 to February 2021, while 92 related cases of de Winter syndrome were identified via PubMed and Web of Science search from January 2000 to June 2025. For all patients, we collected data on age, gender, underlying diseases, family history, primary symptoms, troponin levels, ECG findings, echocardiography results, coronary angiography findings, reperfusion strategies, and in-hospital cardiovascular events for summary and analysis.

The cohort of 105 patients had a median age of 53.7 ± 13.9 years and most were male (98, 93.3%). Smoking (51,48.5%) and hypertension (32,30.5%) were the primary risk factors, while chest pain (103,98.0%) was the predominant presenting symptom. Of the 68 patients (64.8%) with complete HEART score data, 35 (51.5%) scored 4-6 and 33 (48.5%) scored 7-10. On standard 12-lead ECG, the de Winter pattern appeared most frequently in leads V4 (96, 91.4%) and V3 (95, 90.5%). Dynamic ECG evolution was observed in several patients: 24 cases (22.9%) progressed from the de Winter pattern to ST-segment elevation myocardial infarction (STEMI), while 11 cases (10.5%) evolved from STEMI to the de Winter pattern. Four cases (3.8%) showed evolution from the de Winter pattern to Wellens syndrome, and eight cases (7.6%) displayed concurrent de Winter pattern and STEMI. One case evolved from the de Winter pattern to STEMI and then to a normal ECG; another progressed to non-ST-segment elevation myocardial infarction (NSTEMI); one presented with the de Winter pattern and preexcitation syndrome; and one exhibited the de Winter pattern with complete left bundle branch block. Of the 62 patients (59.0%) with available left ventricular wall motion assessment, 53 (85.5%) showed abnormal motion. Left ventricular ejection fraction (LVEF) was reported for 57 patients (54.3%), of whom 37 (64.9%) had an LVEF <50%. Coronary angiography was performed in 104 patients (99.0%), revealing lesions most commonly in the left anterior descending (LAD) (88,84.6%) artery, followed by the right coronary artery (RCA) (24,23.1%) and the left circumflex (LCX) (23,22.1%) artery; single-vessel disease was predominant (67,64.4%). Complications during hospitalization occurred in 86 patients (81.9%). Of these, 28 patients (32.6%) experienced major complications, the most frequent of which was acute heart failure (17, 19.8%).

In middle-aged male patients with chest pain as the primary symptom and risk factors such as smoking and hypertension, the ECG warrants scrutiny, particularly for the characteristic changes and evolution of the de Winter pattern in leads V3 and V4. The presence of these characteristic de Winter changes strongly suggests a single-vessel occlusion, most often of the LAD artery. Therefore, improving the recognition of de Winter syndrome and streamlining the emergency percutaneous coronary intervention (PCI) pathway are clinically important for enhancing reperfusion efficiency and patient outcomes.