HWN Suggests

Wellen’s Syndrome

The peculiarity of this ECG pattern is that it may not appear when the patient has pain. In fact the only finding when the patient has chest pain, may be a small negative deflection at the end of V1 and V2 . The T waves become deeply inverted when the patient is pain free and represents a reperfusion of the myocardium. Cardiac enzymes will be normal in most cases or mildly elevated.

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 The Heart of the Matter - A Case of Recurrent Chest Pain

Though there are many theories, Wellens is thought to most likely arise from intermittent occlusion of a critically stenotic LAD with subsequent thrombus lysis. Patients will present with only small troponin elevation or may be entirely normal. Of note, up to 75% of patients will have an anterior wall MI within one week without intervention. Initial treatment typically involves aspirin load and is followed by antiplatelets, heparin, beta-blockers, and/or nitrates in conjunction with cardiology consultation. Management of this syndrome should involve the following precautions:

 Wellens Syndrome & Pseudo-normalization

So Wellens syndrome is a STEMI equivalent right? That is part of it, but not the whole picture. When we say STEMI or STEMI-equivalent, the image of a fully occluded coronary artery that requires immediate PCI comes to mind. Wellens syndrome is not really a “STEMI” but more of a post-STEMI or a pre-STEMI (along with being a non-STEMI). I’ll explain why.

 Wellens ≠ well

This ECG pattern is indicative of critical stenosis of the proximal LAD. It is not an acute infarction, but it is a predictor of bad things to come – namely anterior wall MI, usually within days to weeks. Patients with this level of stenosis require more than medical management, and stress-testing them may precipitate infarction and death. They require catheterization.

Articles of Interest

A Rare Presentation of a Rare Entity: Wellens Syndrome with Subtle Terminal T Wave Changes

Wellens syndrome is an electrocardiographic (ECG) pattern involving T waves in precordial leads that was first described in 1982 among a group of patients presenting with unstable angina suggestive of critical stenosis of the proximal left anterior descending (LAD) coronary. It is crucial for emergency physicians and internists to be able to recognize these patterns, as they occur in the symptom-free periods and represent a pre-infarction state that needs early intervention. Type A, which is characterized by biphasic T waves, mainly in V2 and V3, poses a significant challenge to recognize the pattern, and failure to do so can lead to devastating outcome. We report a case of type A Wellens syndrome with subtle T wave changes that went unnoticed during the initial assessment and led to start off on a wrong foot.

Cardiology Pearl: Wellens’ Syndrome

Wellens’ syndrome is a critical diagnosis for the emergency physician as it represents a high-grade lesion in the proximal left anterior descending artery. Classically, patients will present with complaints of unstable angina, but women, elderly and diabetics may present atypically. It has been demonstrated that patients with Wellens’ syndrome rapidly progress to anterior infarction, with a mean of 8.5 days from the time of development of the syndrome to acute infarction.

Chief Complaint: Chest Pain, Resolved

Occasionally, T-wave changes are also seen in the other precordial leads. Classically, patients present with a history suggestive of ischemic chest pain, and are often pain-free by the time they arrive at the ED and the EKG is performed. The characteristic EKG pattern develops when the patient is not experiencing chest pain.

EKG Case Report

Wellens’ syndrome, or “LAD coronary T-wave syndrome”, describes the EKG changes that are seen in a patient with a critical proximal LAD stenosis. The pathophysiology is believed to involve transient occlusion of the vessel with spontaneous reperfusion. Type A, which occurs earlier in the disease process, involves biphasic T-waves in the precordial leads and type B, which is more common and occurs later, involves deeply inverted T-waves.

How to recognize Wellens’ Syndrome with a 12-lead EKG

The most common pattern attributed to Wellens’ syndrome is a deeply inverted T wave in the anterior leads (mainly V2-V3, but may also involve V1 and V4, V5 and V6) as noted as “Type 1” in the sample complex below. Note that the second patient in this case exhibited this pattern.

How to Spot Wellens’ Syndrome

This ECG pattern of deep or biphasic precordial T wave inversions, usually in V2 and V3, can be seen during a pain-free period after spontaneous reperfusion of an occluded left anterior descending artery. Immediate cardiology consultation for coronary angiography should be performed due to risk of coronary re-occlusion by unstable plaque.

Intermittent Typical Angina: Remember Wellens’ Syndrome

WS is a diagnostic and management challenge and serial ECG evaluation is still essential for a possible acute coronary syndrome. Having knowledge of all subtle features of this syndrome, could avoid improper discharge of high-risk patients. Definitely, accurate risk stratification, and prompting these patients to an early coronary angiogram and treatment are mandatory to avoid development of a massive anterior myocardial infarction.

Lightning Learning: Wellens Syndrome

Wellens syndrome describes a pattern of deeply inverted or biphasic T-waves in V2 and V3 → this is highly specific for a critical stenosis of the Left Anterior Descending Artery (LAD).

Two EKG Patterns You Must Know Before Your EM Rotation: Wellens and Brugada

Wellens' Syndrome is characterized by specific EKG changes in the precordial leads (typically leads V2 and V3) that are thought to represent reperfusion after an ischemic event. These changes occur in the context of recent, but resolved, chest pain and often normal or minimally elevated cardiac enzymes. There are two types of Wellens' EKG patterns:

Wellens

An interesting back story on this must-not-miss EKG finding in the ED!

Wellens syndrome, reperfusion and reocclusion M

T-wave inversion (TWI) has a wide differential, one of which includes impending coronary artery (re)occlusion. As Dr. Wellens described in 1982, “we can define a subset of people with a proximal LAD lesion, with a 75% chance of losing 35% of their myocardium within 2 weeks, and I believe that they should be distinguished from patients who develop ST segment elevations or depressions during pain. The pattern that I described develops after the pain, and it remains.”[1]. In 1989 he described the same pattern in a larger cohort

Wellens Syndrome: A Possible Precursor

Wellens syndrome is a precursor of left anterior descending (LAD) coronary stenosis. It is characterized by biphasic T waves in V2-V3 (type A) or negative deep T waves in V2-V4 (type B). The ability of emergency physicians, hospitalists, or primary care providers to recognize these early ECG patterns is primordial because the definitive treatment is urgent cardiac catheterization with percutaneous coronary intervention. However, failure to identify a type A or type B Wellens syndrome may lead to devastating outcomes, such as myocardial infarction or even death

Wellens Syndrome: An ECG finding not to miss!

Wellens syndrome is a clinical syndrome characterized by biphasic or deeply inverted T waves in V1-V3 with the history of recent chest pain. Typically, the patient presents to the emergency with intermittent chest pain. He may not have any chest pain at the time of presentation. The cardiac enzymes may or may not be elevated. Hence, it is very critical to pick up this ECG pattern. This ECG pattern is highly specific for critical proximal stenosis of left anterior descending artery.

Wellens' Syndrome: A Case Study

ACS broadly can be subdivided into STEMI (30%), NSTEMI (25%), and unstable angina (38%). STEMI and NSTEMI are both categories of myocardial infarction differentiated by EKG pattern and pathophysiology; both present with elevations in cardiac enzymes, indicating death of cardiac tissue. Unstable angina is often a warning sign, indicating new plaque instability. As opposed to stable angina, unstable angina occurs suddenly, at rest or with minimal exertion (or at lesser degrees of exertion than the individual's previous angina--"crescendo angina"). New onset angina is also considered unstable angina, since it suggests a new problem in a coronary artery. Wellens’ syndrome is a subtle subcategory of unstable angina characterized by specific EKG changes that represent significant proximal LAD stenosis that will often progress to an anterior wall MI if untreated.

Wellens’ Syndrome

Wellens’ syndrome is a preinfarction stage of coronary artery disease and heralds an impending extensive myocardial infarction of the anterior wall.1,3 It is typified by anginal chest pain, characteristic EKG changes that usually occur after chest pain has resolved, and negative cardiac biomarkers.

Wellens’ syndrome: a pattern to remember

The ECG shall be the only indication of an imminent massive anterior infarction. So, a timely diagnostic and therapeutic approach will be able to prevent a massive infarction in LAD coronary artery territory and reduce the high morbidity and mortality associated with coronary artery disease.

Wellens’ Syndrome: Is it on your radar?

Wellen’s Syndrome was first described in 1982 in which 75% of patients with t wave inversions in V2-V4 went on to have an acute myocardial infarction (MI). This was again repeated in 1989, and showed that all patients with this morphology had >50% LAD stenosis. The incidence in the United States is about 10-15%.

Resources

Life in the Fastlane

Wellens Syndrome is a clinical syndrome characterised by biphasic or deeply inverted T waves in V2-3, plus a history of recent chest pain now resolved. It is highly specific for critical stenosis of the left anterior descending artery (LAD).

Maimonides Emergency Medicine

The treatment of choice to improve both morbidity and mortality in Wellens’ Syndrome is early PCI- these patients need to go to the cath lab! Stress testing is contraindicated since it can induce a massive anterior myocardial infarction

StatPearls

Wellens syndrome describes an abnormal electrocardiographic (ECG) pattern, deeply inverted T waves in leads V2 and V3, that are secondary to proximal LAD stenosis. Patients often present to the emergency department pain-free and elevated cardiac enzymes are usually normal or only slightly elevated.