“Wellens ≠ well”

Resident Clinical Pearl – November 2016

Mandy Peach, PGY1 iFMEM, Dalhousie University, Saint John, New Brunswick

Reviewed by Dr. David Lewis

 

It’s 7:30 in the morning, you are just starting your shift as a new R1 (you haven’t had coffee yet) and a 69 yo male rolls into the ED with chest pain ongoing since 2am. He has no known cardiac history (hasn’t seen a doctor in years) and is on no medications other than multivitamins. He is an active guy, doesn’t smoke or drink and has no pertinent family history.

On speaking with him he says the pain has actually subsided en route in EMS. You are passed his ECG¹ –

Your immediate concern is to look for ST changes to determine if this guy is having a STEMI requiring immediate catheterization…but you don’t see any.

However, T-wave inversions in V1-V5 catch your eye, and they are fairly deep. Just ischemic changes?

Your staff cleverly hints – “This guy isn’t well”.

 

Wellens Syndrome

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 weeks². Patients with this level of stenosis require more than medical management, and stress-testing them may precipitate infarction and death³.  They require catheterization.

Criteria to diagnose Wellens includes¹:

• Biphasic T waves (Type A) or deeply inverted T waves (Type B) in V2-3 (may extend to V1-6)
• Isoelectric or minimally-elevated ST segment (< 1mm)
• No precordial Q waves
• Preserved precordial R wave progression
• Recent history of angina
• ECG pattern present in pain-free state
• Normal or slightly elevated serum cardiac markers

The reasoning behind the T-wave pattern is as follows¹:

When our patient had the chest pain at 0200 it was likely transient ischemia secondary to occlusion of the LAD. By the time he arrived to the ER the clot had spontaneously lysed and he was pain free. No ST elevation was seen, but the reperfusion of the LAD caused T wave changes – usually first biphasic (Type A) that progress to deeply inverted T waves (Type B)¹:

 

But don’t be fooled – the differential for deeply inverted T waves is extensive and includes several important and potentially life-threatening conditions including¹:

Pulmonary Embolism¹ http://i0.wp.com/lifeinthefastlane.com/wp-content/uploads/2011/10/ecg-wellens-syndrome-1.jpg

Brugada Syndrome¹ http://i2.wp.com/lifeinthefastlane.com/wp-content/uploads/2009/09/Brugada-type-1.jpg

Hypokalemic¹ http://i2.wp.com/lifeinthefastlane.com/wp-content/uploads/2011/02/U-waves-in-hypokalaemia.jpg

 

And let’s not forget other high risk ECG presentations of chest pain that shouldn’t be missed as they involve a considerable section of the left ventricle and thus require activation of the cath lab:  http://rebelem.com/five-ecg-patterns-you-must-know/

1. First Diagonal Branch of the LAD occlusion
2. De Winters – proximal LAD occlusion
3. Left Main Coronary Artery Stenosis
4. Posterior Wall MI

 

So what happened with our guy?

The patient in this case did go on to have cardiac catheterization that same morning, most likely preventing a catastrophic MI.

 

What can you do in ED?

1. Recognize the pattern
2. Immediate consult to interventional cardiology
3. Treat as unstable angina – chewable ASA and load with anti-platelet therapy in anticipation of catheterization.

 

Take away point –  Wellens ≠ well. The money isn’t always on ST changes alone, always check the T waves in V2-V3 for biphasic pattern or inversion and consider high risk ischemic ECG patterns in absence of chest pain and cardiac marker abnormalities. Poor outcomes can be prevented in these patients by consulting Cardiology and admitting for early cath.

 

 

References:

1. http://lifeinthefastlane.com/ecg-library/wellens-syndrome/
2. De Zwaan, C., Bar, F., Wellens, H. (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.
3. Tandy, R., Bottomy, D., Lewis, J. (1999). Wellens’ Syndome. Annals of Emergency Medicine, 33 (3): 347-351.
4. De Zwaan, C., Bar, F., Janssen, J., Cheriex E., Dassen W., Brugada P., Penn, O., and Wellens, H. (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): 657-65