Cardiology Pearl: Wellens' Syndrome

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Originally Published: Modern Resident, Aug/Sep 2011

Original Author: Alan Sielaff, MS IV Loyola University Chicago, Stritch School of Medicine

Submitted by: Rachel Engle, DO Communications Committee Co-Chair
 
A 63 year old female with a history of hepatitis C and diabetes mellitus presents to the emergency department after experiencing acute substernal chest pain, SOB and emesis during a routine visit to her PCP earlier this afternoon. All symptoms spontaneously resolved shortly prior to her arrival in the ED. She has no other complaints and a normal physical exam. Her EKG is shown above.

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.¹ A set of criteria has been established in the diagnosis of Wellens' syndrome which include symmetric and deeply inverted T waves in leads V2 and V3, sometimes in leads V1, V4, V5, and V6 or biphasic T wave in leads V2 and V3; plus isoelectric or minimally elevated (1mm) ST segment; no precordial Q waves; history of angina; pattern present in pain-free state; normal or slightly elevated cardiac serum markers.^2-6 It is key to note in the above criteria that patients with Wellens' syndrome typically display the characteristic EKG changes during chest pain-free intervals.⁶ Patients with suspected Wellens' syndrome should have immediate cardiology consultation. The above patient was taken to the cardiac catheterization lab where it was revealed that she had a >95% occlusive lesion in her proximal LAD requiring stent placement.

References:

1. de Zwaan C, Bar FW, Wellens HJ. Characteristic electrocardiographic pattern indicating a critical stenosis high in left anterior descending coronary artery in patients admitted because of impending myocardial infarction. Am Heart J. Apr 1982;103(4 Pt 2):730-6.
2. Tandy TK, Bottomy DP, Lewis JG. Wellens' syndrome. Ann Emerg Med. Mar 1999;33:347-51.
3. Ondrusek RS: Spotting an MI before it's an MI. RN 1996;59: 26-30.
4. Kahn EC, Keller KB. Wellens' syndrome in the emergency department. J Emerg Nurs 1991;17:80-84.
5. Paul S, Johnson P: Early recognition of critical stenosis high in the left anterior descending coronary artery. Heart Lung 1990;19:27-29.
6. Rhinehardt J, Brady WJ, Perron AD, Mattu A. Electrocardiographic manifestations of Wellens' syndrome. Am J Emerg Med. Nov 2002;20:638-43.