|EKG #1 (day of presentation)|
You then compare it to his EKG from two days ago when he came in for chronic diarrhea (and had mentioned some intermittent chest pain):
|EKG #2 (EKG from two days prior to presentation)|
... and compare it again with his EKG from 1 year before during an admission for chest pain in which he had a negative cardiac stress test:
|EKG #3 (EKG from one year prior to presentation)|
Whenever you see T wave abnormalities in a patient with possible unstable angina, you need consider an electrocardiographic syndrome of critical LAD stenosis that was first described by Hein Wellens and colleagues in 1982 and thus is referred to as Wellen's Syndrome.
Wellens' Syndrome is a clinical-electrocardiographic syndrome with the following criteria [1,2]:
- Prior history of chest pain - i.e. the patient is now chest pain free
- Little or no cardiac enzyme elevation
- No pathologic precordial Q waves
- Little or no ST-segment elevation
- Symmetric or deeply inverted T waves in leads V2 and V3 (and occasionally the other precordial leads as well) OR biphasic T wave in leads V2 and V3
As noted above, Wellens' syndrome has variable electrocardiographic presentations. It comes in one of two forms: symmetric, deep T wave inversions (75% of cases) or biphasic T waves (25% of cases) [2,3]. These T wave inversions are notable for their steep angle of descent and depth. While changes in V2, V3 are typical, T-wave abnormalities may also be present in the other precordial leads (V1, V4, V5, V6) as well. Wellens' syndrome is dynamic, which is one of the features that distinguishes it from more benign causes of precordial T wave inversion such as LVH with strain. Dr. Steve Smith's ECG blog has this post on distinguishing benign T wave inversion from Wellens' syndrome.
|Figure 1 from the original paper describing Wellens' syndrome (Ref 3). Note the two patterns of precordial T wave abnormalities.|
Given the high risk of progression to left anterior wall myocardial infarction and death, patients with Wellens' syndrome should NOT undergo a cardiac stress test.  They should go cardiac catheterization sooner rather than later (probably from the ED in ideal circumstances) as they are extremely high risk for progression to anterior STEMI:
|Figure 2 from the original paper demonstrating progression from Wellens' to STEMI (and death).|
After intervention and with time, ninety percent of patients with Wellens' syndrome will regain a normal ST-T segment . While an exact time period for resolution of EKG changes was not specified in Wellens' paper, ST-T wave abnormalities were more likely to persist in patients who continued to have chest pain, undergo medical therapy, or had extensive collateral circulation on cardiac catheterization suggesting longer term and more permanent cardiac injury.
So what happened with our patient? After his second presentation with unstable angina and biphasic T waves, the emergency physician diagnosed him with Wellens' syndrome and admitted him to the Cardiology service where he was taken for cardiac catheterization and underwent stenting of a 90% lesion in his proximal LAD. While his hospital discharge summary announced that "it was felt that his chest pain was still most likely to costochondritis or cocaine use", the change in T wave morphology on his post-cath EKG suggests otherwise:
Submitted by Maia Dorsett (@maiadorsett), PGY-3
Faculty Reviewed by Brent Ruoff
Thank you to Julianne Dean and Chris Palmer for the cases (and patient advocacy)
Tandy, T. K., Bottomy, D. P., & Lewis, J. G. (1999). Wellens’ syndrome. Annals of emergency medicine, 33(3), 347-351.
Rhinehardt, J., Brady, W. J., Perron, A. D., & Mattu, A. (2002). Electrocardiographic manifestations of Wellens' syndrome. The American journal of emergency medicine, 20(7), 638-643.
 de Zwann, C., Bar F.W., Wellens, H.J. (1982). Characteristic electrocardiographic pattern indicating a critical stenosis high in left anterior descending coronary artery in patients admitted because of impending myocardial infarction." American heart journal, 103(4), 730-736.
 de Zwaan, C., Bär, F. W., Janssen, J. H., Cheriex, E. C., Dassen, W. R., Brugada, P., ... & Wellens, H. J. (1989). Angiographic and clinical characteristics of patients with unstable angina showing an ECG pattern indicating critical narrowing of the proximal LAD coronary artery. American heart journal, 117(3), 657-665.