Wellens Syndrome

Last week Valentino posted this ECG for discussion and talked about Wellens syndrome and how to spot it. Below is information taken from LITFL about the clinical significance of Wellens and what the diagnostic criteria are.

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).

Patients may be pain free by the time the ECG is taken and have normally or minimally elevated cardiac enzymes; however, they are at extremely high risk for extensive anterior wall MI within the next few days to weeks.

Due to the critical LAD stenosis, these patients usually require invasive therapy; do poorly with medical management; and may suffer MI or cardiac arrest if inappropriately stress tested.

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
  • Recent history of angina
  • ECG pattern present in pain-free state
  • Normal or slightly elevated serum cardiac markers

Understanding The T Wave Changes

The following sequence of events is thought to occur in patients with Wellens syndrome:

  • A sudden occlusion of the LAD, causing a transient anterior STEMI. The patient has chest pain & diaphoresis. This stage may not be successfully captured on an ECG recording.
  • 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. The T wave morphology is identical to patients who reperfuse after a successful PCI.
  • If the artery remains open, the T waves evolve over time from biphasic to deeply inverted.
  • The coronary perfusion is unstable, however, and 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 — so-called “pseudo-normalisation”. The T waves switch from biphasic/inverted to upright and prominent. This is a sign of hyperacute STEMI and is usually accompanied by recurrence of chest pain, although the ECG changes can precede the symptoms.
  • If the artery remains occluded, the patient now develops an evolving anterior STEMI.

This sequence of events is not limited to the anterior leads — similar changes may be seen in the inferior or lateral leads, e.g. with RCA or circumflex occlusion.

Source: https://litfl.com/wellens-syndrome-ecg-library/

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