Extreme cold waves (ECWs) occurring over the conterminous United States (US) are studied through a systematic identification and documentation of their local synoptic structures, associated large-scale meteorological patterns (LMPs), and forcing mechanisms external to the US. Focusing on the boreal cool season (November–March) for 1950‒2005, a hierarchical cluster analysis identifies three ECW patterns, respectively characterized by cold surface air temperature anomalies over the upper midwestern (UM), northwestern (NW), and southeastern (SE) US. Locally, ECWs are synoptically organized by anomalous high pressure and northerly flow. At larger scales, the UM LMP features a zonal dipole in the mid-tropospheric height field over North America, while the NW and SE LMPs each include a zonal wave train extending from the North Pacific across North America into the North Atlantic. The Community Climate System Model version 4 (CCSM4) in general simulates the three ECW patterns quite well and successfully reproduces the observed enhancements in the frequency of their associated LMPs. La Niña and the cool phase of the Pacific Decadal Oscillation (PDO) favor the occurrence of NW ECWs, while the warm PDO phase, low Arctic sea ice extent and high Eurasian snow cover extent (SCE) are associated with elevated SE-ECW frequency. Additionally, high Eurasian SCE is linked to increases in the occurrence likelihood of UM ECWs.