Abstract. Wellens’ syndrome is an extremely relevant issue in modern cardiology. Wellens’ syndrome is quite often untimely diagnosed, and the patient’s management is the same as in case of unstable angina. Since without myocardial revascularization, widespread myocardial infarction develops within the following days or weeks, myocardial revascularization is needed as soon as possible. Characteristic changes on the electrocardiogram in case of Wellens’ syndrome include biphasic (type A) or inverted (type B) T waves in leads V2-V3, which sometimes are seen in other precordial leads. There must be a history of recent angina in addition to these electrocardiogram changes. Troponin is usually negative; however, it can be slightly elevated. Sometimes, patients with classic electrocardiogram changes and clinical picture typical for Wellens’ syndrome do not show hemodynamically significant stenosis of the left anterior descending artery typical for this syndrome. In such cases, “pseudo-Wellens’ syndrome” is observed. Three cases of angiographically confirmed Wellens’ syndrome and one case of pseudo-Wellens’ syndrome are presented in this paper. All the patients with Wellens’ syndrome had significant lesions of the left anterior descending artery. One patient had a triple-vessel lesion, and the other two had a single-vessel lesion. Troponin I was within normal limits in one patient, and slightly elevated and in the other two. These patients underwent successful myocardial revascularization (percutaneous coronary intervention); pharmacological therapy was prescribed.
Multi-vessel coronary artery disease is quite a common state, which is often diagnosed by coronary angiography in patients with both stable coronary artery disease and acute coronary syndromes. Major difficulties in percutaneous coronary intervention include stent thrombosis and the need for antiplatelet therapy (aspirin and a P2Y12 inhibitor). Stent thrombosis leads to the recurrence of myocardial infarction and may occur within the first few hours after percutaneous coronary intervention. The use of dual antiplatelet therapy, especially that combined with low-molecular-weight heparin in the first days after myocardial infarction, poses a risk of bleeding, which often occurs in real clinical practice. Among P2Y12 inhibitors, ticagrelor causes bleeding somewhat more frequently than clopidogrel. A case of multi-vessel coronary artery disease is described in this paper. Coronary angiography revealed right-dominant circulation; occlusion of the proximal and medial segments of the right coronary artery, thrombolysis in myocardial infarction flow grade 0; stenosis of the left main coronary artery (50-60%), thrombolysis in myocardial infarction flow grade 2; diffuse stenosis of the medial and distal segments of the left anterior descending artery, thrombolysis in myocardial infarction flow grade 1; stenosis of the proximal segment of the left circumflex artery (> 75%), thrombolysis in myocardial infarction flow grade 1. The patient underwent percutaneous coronary intervention; the stents were implanted in the infarct-dependent right coronary artery. The clinical course was complicated by early stent thrombosis with subsequent thrombus extraction; a day later melena developed. Bleeding was stopped, the intensity of antithrombotic therapy was reduced: the combination of aspirin and ticagrelor was replaced by the combination of aspirin and clopidogrel. Six weeks after stenting of the infarct-dependent coronary artery, complete myocardial revascularization (hybrid intervention) was performed: coronary artery bypass grafting [the left internal mammary artery → the left anterior descending artery], coronary autogenous bypass grafting [the aorta → the right coronary artery and the aorta → the left circumflex artery]. The role of fractional flow reserve or instantaneous wave-free ratio-controlled complete myocardial revascularization techniques is discussed. The following algorithm for myocardial revascularization was used: percutaneous coronary intervention for the right coronary artery + coronary artery bypass grafting-3: the left internal mammary artery → the left anterior descending artery, the aorta → the left circumflex artery, the aorta → the right coronary artery.
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