Wellens’ SyndromeGeoff Lampard PGY-1Jan 6th 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, O2, 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 angina4. Pattern in pain free

state5. 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

Qu

estio

ns

?

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 1982. 103:730-736

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 1989. 117:657-665

Rhinehardt J, Brady WJ, Perron AD, Mattu A. Electrocardiographic Manifestations of Wellens’ Syndrome. Am Journal Emerg Med 2002. 20:638-643.

Lilaonitkul M, Ronbinson K, Roberts M. Wellens’ Syndrome: significance of ECG pattern recognition in the emergency department. Emerg Med J. 2009. 26:750-751