Wellens’ Syndrome Geoff Lampard PGY-1 Jan 6 th 2011 ECG Rounds

Case 1  55yo male with history of stable angina  Presents to ED with ischemic chest pain

…. pain resolves with NTG…..  Serum TnT returns normal  What do you see in the ECG?

Case 2  57 yo male with 4/10 pressure-like chest pain  ASA, O 2, 2 x SL NTG sprays with EMS  Pain now improving

… and pain free…….

Case 3  54M with pressure like RSCP, diaphoresis  NTG and morphine relieves pain. ECG follows:

Now 1 minute into the stress test……  Anterior wall STEMI.  Immediately taken for cath and found an extensive proximal LAD lesion

The widowmaker

Wellens’ Syndrome First recognised in early 1980’s in a subgroup of UA patients with precordial T- wave changes in the pain free period who developed large anterior MI’s. All patients who met their criteria had ≥ 50% LAD stenosis 26/145 patients admitted for UA developed characteristic ECG findings at or within 24hrs of admission

Key concept #1 Wellens is relatively common (14-18% of UA patients)

½ way through study, medical management was aborted and all were given preferential angiography 75% of medically managed patients developed anterior MI’s within 3 weeks

Key concept #2 Wellens is a preinfarction stage of CAD Mean time to infarction: 8.5 days

1.ECG findings: a.Symmetric, deeply inverted T waves in V2-3. Occasionally in V1,V4-6, or b.Biphasic T waves in V2-3 plus c.Isoelectric or minimally elevated (<1mm) ST 2.No precordial Q-waves 3.History of angina 4.Pattern in pain free state 5.Normal or slightly elevated serum markers Criteria

Key concept #3 It is best seen during the pain- free period…. Get serial or pain-free ECG’s from UA patients!

Deep Inverted (figures A-C) ~75% of Wellens Biphasic pattern (D-F) ~25% of cases

But remember, the differential for t-wave inversion is large. Acute ischemia LVH BBB Late pericarditis PE CNS pathology Myocarditis Digitalis Old MI etc. etc. etc.

Key concept #4 Patients need early angiography. Get cardiology involved in the ED!

Case 1, pain free

Case 2, pain free

Case 3, pain free….

Wellens’ is not uncommon. Remember the 2 characteristic ECG changes Get a pain-free ECG! Wellens’ is a sign of impending MI. Requires urgent assessment.

Recommended further reading

Questions? De Zwann C, Bar FW, Wellens JHH: 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 : De Zwann C, Bar FW, Janssen JH, et al: Angiographic and clinical characteristics of patents with unstable angina showing an ECG pattern indicating critical narrowing of the proximal LAD coronary artery. Am Heart J : Rhinehardt J, Brady WJ, Perron AD, Mattu A. Electrocardiographic Manifestations of Wellens’ Syndrome. Am Journal Emerg Med : Lilaonitkul M, Ronbinson K, Roberts M. Wellens’ Syndrome: significance of ECG pattern recognition in the emergency department. Emerg Med J :