Wellens Syndrome: An ECG finding not to miss!

Selva Maheshwari1, Deep Chandh Raja2,*, Vidya Saketharaman3

1Physician Assistant, Kauvery Heart Rhythm Services, Kauvery Hospital, Chennai

2Cardiologist and Clinical Lead of Cardiac Electrophysiology, Kauvery Heart Rhythm Services, Kauvery Hospital, Chennai

3Consultant, Emergency Medicine, Kauvery Hospital, Chennai

*Correspondence: drdeepchandh@kauveryhospital.com

Case Presentation

A 70-year-old male came to the emergency department with a history of retrosternal chest pain on and off, and profuse sweating for 12 h. However, on presentation, there was no chest pain.

The blood troponins were only mildly elevated. Echocardiography showed mild hypokinesia of the interventricular septum.

The 12-lead ECG showed two different patterns at different points of time, as shown in Fig. 1.

As shown in Fig. 1A, 12-lead ECG revealed biphasic T wave inversion in V1-V3. A few minutes later, as shown in Fig. 1B, 12-lead ECG revealed deep symmetric T wave inversions in V1-V6. Both the patterns suggest Wellens syndrome.

An emergency coronary angiogram was performed, which showed severe 99% ostio-proximal left anterior descending artery (LAD) stenosis (Fig. 1C).

Coronary angioplasty was performed to ostio-proximal LAD and 3 x 12 mm ONYX drug eluting stent was successfully placed. The patient was discharged after observation for 2 days.

wellen

Fig. 1. Panel A shows the 12-lead ECG at presentation; Panel B shows the 12-lead ECG after a few minutes of presentation; Panel C shows the angiographic picture in right anterior oblique caudal view showing 99% stenosis (*) of the proximal left anterior descending coronary artery

What is Wellens syndrome?

Wellens syndrome is a clinical syndrome characterized by biphasic or deeply inverted T waves in V1-V3 with the history of recent chest pain. Typically, the patient presents to the emergency with intermittent chest pain. He &may not have any chest pain at the time of presentation. The cardiac enzymes may or may not be elevated. Hence, it is very critical to pick up this ECG pattern. This ECG pattern is highly specific for critical proximal stenosis of left anterior descending artery.

When was this first described?

Dr. Hein Wellens and colleagues first identified this syndrome in early 1980s. [1] They noted this finding in 14% to 18% of patients admitted for unstable angina. They also noted that 75% of patients with these ECG findings went on to develop acute, anterior wall myocardial infarction.

Types of Wellens ECG patterns

There are two types based on T wave abnormality

  1. Type A: Biphasic with initial positivity and terminal negativity of T waves in V1-V3 chest leads
  2. Type B: Deep and symmetrically inverted T waves in V1-V6 chest leads

In the patient described above, both the patterns were seen at different points of time. Dr Wellens had also described that Type A pattern can evolve into Type B pattern over time and can persist even after revascularization of the coronary vessel.

Diagnostic criteria for Wellens syndrome

  1. Deeply inverted or biphasic T waves in V2-3
  2. ECG pattern present in pain-free state
  3. Minimally-elevated ST segment ( 1 mm)
  4. No precordial Q waves
  5. Preserved precordial R wave progression
  6. Recent history of angina
  7. Normal or slightly elevated serum cardiac enzymes

Pathogenesis of Wellens ECG pattern

This pattern occurs because of &temporary obstruction of the LAD coronary artery. A critical stenosis of the proximal LAD artery with trickling of flow across the vessel is the reason for intermittent chest pain. This is a &pre-infarction state with risk of acute 100% occlusion of the vessel. As the chest pain may not be present or the blood troponins may not be elevated, the ECG patterns are the only recognizable signs to pick up Wellens syndrome. This ECG pattern, when recognized, should be treated in the same lines of ST-elevation myocardial infarction, by giving loading doses of anti-platelets and anti-thrombotics.

References

  1. Zhou L, et al. Wellens’ syndrome: incidence, characteristics, and long-term clinical outcomes. BMC Cardiovasc Disord. 2022;22(1):176.
Deep-Chandh-Raja

Dr. Deep Chandh Raja. S

Consultant Cardiologist and Clinical Lead – Cardiac Electrophysiology

Vidya-Saketharaman

Dr. Vidya Saketharaman

Emergency Care

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