Wellens' syndrome

Background

  • First described in 1982, a set of EKG changes specific for critical, proximal stenosis of LAD
    • At risk for extensive anterior wall myocardial infarction due to proximal LAD stenosis[1]
      • In the original study, a subset of patients fared poorly with medical management of “impending myocardial infarction”
      • 75% of patients with these findings will later develop anterior MI (if not treated with PCI)
    • Characteristic EKG changes: T wave abnormality (2 types, shown below) associated with the stenosis[2]
  • Commonly described as a STEMI equivalent, but per the 2022 ACC Expert Consensus Decision Pathway, it's instead categorized as an ischemic change[3]
    • This is because patient is not currently having an MI; rather, it's a post-ischemic change

Clinical Features

  • Symptoms of Myocardial infarction or ischemia
  • Symptoms have often resolved at presentation
  • May have previous recent episodes of angina or anginal equivalents
  • Initial cardiac enzymes are frequently normal or slightly elevated[4][5]
  • Cocaine use may cause pseudo-Wellens due to vasospasm without critical stenosis[6]

Differential Diagnosis

  • High voltage
  • PE
  • RBBB
  • Hypokalemia
  • CNS Injury
  • Persistent Juvenile T-wave pattern
  • Digitalis Effect
  • "Normal variant" STE with biphasic T-wave[7]
    • Common in young, healthy, Black males
    • Patterns that are NOT found in Wellen's
      • High voltage complexes
      • Notching at J-point ("fishhook")
      • Concave upward ST segment followed by steep drop in T wave

ST Elevation

Evaluation

  • History of chest pain
    • ECG may be normal during episode of pain
  • Normal or slightly-elevated cardiac enzymes
  • No precordial Q-waves
  • Isoelectric or <1mm ST-segment elevation
  • Wellens' sign present in pain-free state
    • Wellens' sign during pain-free state plus recent history of angina and normal to slightly elevated cardiac enzymes = Wellen's syndrome
    • Findings can be transient (persists for hours after pain has resolved and then disappears)

Two T-wave Characteristics (at times terms are reversed in the literature or labeled Type I and II):

  • Type A (25%)
    • Biphasic T-wave in V2/V3
  • Type B (75%)
    • Deep, symmetrically inverted T-waves in V2/V3

Wellens.png

  • IF there is acute occlusion MI, Wellens T wave patterns may normalize and convert to ST elevations
  • Note Wellens criteria should not be applied to patients with LVH

Management

  • Treat similarly to MI, including antiplatelets and anticoagulation[8]
  • Urgent cardiac catheterization is the definitive treatment
  • Stress testing contraindicated
    • Can precipitate an acute myocardial infarction and sudden death

Disposition

  • Admit

See Also

External Links

Mattu ECG Case - Wellens' Syndrome

References

  1. de Zwaan C, Bär FW, Wellens HJ. 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(4 Pt 2):730-736.
  2. Rhinehardt J, Brady WJ, Perron AD, Mattu A. Electrocardiographic manifestations of Wellens' syndrome. American Journal of Emergency Medicine. 2002;20(7):638-643. doi:10.1053/ajem.2002.34800.
  3. 2022 ACC Expert Consensus Decision Pathway on the Evaluation and Disposition of Acute Chest Pain in the Emergency Department: A Report of the American College of Cardiology Solution Set Oversight Committee, Journal of the American College of Cardiology, Volume 80, Issue 20,2022,Pages 1925-1960,ISSN 0735-1097.
  4. Ünlüer EE et al. Red Flags in Electrocardiogram for Emergency Physicians: Remembering Wellens' Syndrome and Upright T wave in V1. West J Emerg Med. 2012 May; 13(2): 160–162.
  5. Kannan L and Figueredo VM. Wellens' Syndrome. Jan 1, 2015. N Engl J Med 372;1.
  6. Dhawan SS. Pseudo-Wellens’ syndrome after crack cocaine use. Can J Cardiol. 2008; 24(5):404.
  7. Wang, et al. ST-segment elevation in conditions other than acute myocardial infarction. NEJM 2003, 349:2128-2135.
  8. Miner B, Grigg WS, Hart EH. Wellens Syndrome. [Updated 2023 Jul 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.