Wellen"s syndrome

A60 years old male, came to JIPMER,Pondicherry, India with chief complaints of chest pain on and off since last month which increases on exertion. Patient came to JIPMER hospital one month back, ECG done at that time is shown below. 

ECG 1(Click  on the image to enlarge it)

ECG is showing normal sinus rhythm at 64 beats per minute, normal axis, biphasic T wave seen in lead V2-V4, T wave inversion seen in lead V5,V6. 

Patient cardiac marker were negative. So diagnosis of Acute coronary syndrome with unstable angina was made. Patient was planned for coronary angiography planned but could not be done due to logistic reason. Patient went home and again come back to JIPMER hospital emergency with acute onset retrosternal chest pain since one week, increased since 3 hours of duration. ECG of the patient done is shown below

ECG 2(Click on the image to enlarge it)

ECG is showing normal sinus rhythm at 88 beats per minute, normal axis, normal PR interval,  Biphasic T wave with Deep T wave inversion seen in lead V2-V4, ST segment depression with T wave inversion seen in lead V5,V6, No evidence of Q wave anywhere or any poor R wave progression so the ECG is suggestive of classical Wellen"s syndrome.

ECG 3( Done after two hours of hospital  admission)

ECG after 2 hours is showing increase in T wave inversion in lead V2-V6, loss of biphasic T wave in lead V2-V4, no Q wave or no poor R wave progression

ECG done again after 1 minute of the above ECG

ECG is showing T wave inversion in lead V2-V6

ECG done two days after admission to the hospital shown below

ECG is still showing T wave inversion in lead V2-V6

Patient cardiac markerwas done and troponin I was found to be elevated. Coronary angiography of the patient showed proximal left anterior descending artery occlusion ( 90% ). Patient was planned for percutaneous coronary intervention and he is awaiting procedure.

Little about Wellen's syndrome

Wellen's syndrome was first described by Gerson and colleagues in 1980 as an inverted U-wave, and again in 1982 by De Zwaan, Wellens and colleagues as Wellen's syndrome.

 It consists of a characteristic EKG finding suggesting severe stenosis of the proximal LAD artery, which will develop into an acute anterior wall MI within a few days to weeks in 75% of untreated patients.

Wellen's syndrome is diagnosed based on the classic T-wave findings seen on an EKG taken when the patient is pain-free. These T-wave changes represent reperfusion of the myocardium.

There are two variations of Wellen's syndrome T-wave. Type A is the more common abnormality, occurring in 75% of cases, and is characterized by deeply inverted T-waves in V2 and V3. Type B occurs in 25% of cases and is characterized by biphasic T-waves in V2 and V3.

The diagnostic leads for T-waves of Wellens' syndrome are V2 and V3, corresponding with a lesion between the first and second septal branches of the LAD. However, if the lesion is more proximal in the LAD, the T-wave changes will be more widely spread along the precordial leads.

An EKG obtained during episodes of pain will demonstrate upright T-waves with possible ST segment elevation or depression, but an isoelectric ST segment may also be seen.  Cardiac enzymes will be normal or mildly elevated. 

 These changes are easily missed, and therefore it is critical for the Emergency Physicians to be aware of them. It is unlikely that any Emergency Physician would miss the deeply inverted T-waves that occur in this syndrome when the patient is pain-free, as is shown in our case, but the significance of these findings must also be recognized. Emergency angiography is justified with either of these EKG presentations, with the hope of avoiding an extensive anterior wall MI through early intervention.[

Wellens syndrome is also referred to as LAD coronary T-wave syndrome. Syndrome criteria include the following:

• • Characteristic T-wave changes
  • History of anginal chest pain
  • Normal or minimally elevated cardiac enzyme levels
  • ECG without Q waves, without significant ST-segment elevation, and with normal precordial R-wave progression
  Recognition of this ECG abnormality is of paramount importance because this syndrome represents a preinfarction stage of coronary artery disease (CAD) that often progresses to a devastating anterior wall MI
• Thank you

Reference

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