Wellens' syndrome

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Definition:

  • Wellens’ syndrome is a pattern of deeply inverted or biphasic T waves in V2-3, which is highly specific for a critical stenosis of the left anterior descending artery (LAD)
  • There are two patterns of T-wave abnormality in Wellens’ syndrome:
    • Type A = Biphasic, with initial positivity & terminal negativity (25% of cases)
    • Type B = Deeply and symmetrically inverted (75% of cases)

What happens exactly?

  1. Sudden occlusion of the LAD, causing a transient anterior STEMI. The patient has chest pain & diaphoresis.
  2. Re-perfusion of the LAD (e.g. due to spontaneous clot lysis or prehospital aspirin). The chest pain resolves. ST elevation improves and T waves become biphasic or inverted.
  3. If the artery remains open, the T waves evolve over time from biphasic to deeply inverted.
  4. The LAD can re-occlude at any time. If this happens, the first sign on the ECG is an apparent normalisation of the T waves (“pseudo-normalisation”). The T waves switch from biphasic/inverted to upright.
  5. If the artery remains occluded, the patient now develops an evolving anterior STEMI.

Diagnostic criteria:

  • Deeply inverted or biphasic T waves 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

Why is this important?

  • Myocardial infarction occurs within a mean of 6 – 8.5 days after admission
  •  Myocardial infarction occurs within a mean of 21.4 days after symptoms

Management:

  • Oxygen, aspirin, nitroglycerin, and heparin are the mainstay medical treatments of unstable angina, which is what Wellens’ Syndrome is, but in this specific case early cardiac revascularization is very important!
  • The treatment of choice to improve both morbidity and mortality in Wellens’ Syndrome is early PCI- these patients need to go to the cath lab!
  • Stress testing is contraindicated since it can induce a massive anterior myocardial infarction

Sources:

Life in the Fastlane, R.E.B.E.L EM

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