Myocardial bridging—an unusual cause of Wellens syndrome

Abstract

Rationale: Coronary chest pain is usually ischemic in etiology and has various electrocardiographic presentations. Lately, it has been recognized that myocardial bridging (MB) with severe externally mechanical compression of an epicardial coronary artery during systole may result in myocardial ischemia. Such a phenomenon can be associated with chronic angina pectoris, acute coronary syndromes (ACS), coronary spasm, ventricular septal rupture, arrhythmias, exercise-induced atrioventricular conduction blocks, transient ventricular dysfunction, and sudden death. Patient concerns: We report the case of a 58-year-old woman presenting with recurrent episodes of constrictive chest pain during exercise within the last 2 weeks. Except for obesity, general and cardiovascular clinical examination on admission were normal. Diagnoses: The resting 12 lead electrocardiogram (ECG) revealed changes typically for Wellens syndrome. High-sensitive cardiac troponin I was normal. We established the diagnosis of low-risk non-ST-segment elevation acute coronary syndrome with a Global Registry of Acute Coronary Events risk score of 92 points. Interventions: The patient underwent coronary angiography, who showed subocclusive dynamic obstruction of the left anterior descending artery due to MB. Outcomes: The patient was managed conservatively. Her hospital course was uneventful and she was discharged on pharmacological therapy (clopidogrel, bisoprolol, amlodipine, atorvastatin, and metformin) with well-controlled symptoms on followup. Lessons: MB is an unusual cause of myocardial ischemia. Wellens syndrome is an unusual presentation of ACS. We present herein a rare case of Wellens syndrome caused by MB. This case highlights the importance of subtle and frequently overseen ECG findings when assessing patients with chest pain and second, the importance of considering nonatherosclerotic causes for ACS.

Wellens Syndrome: Single Centre Study and Literature Review

“…The prevalence and prognostic implications of Wellens' sign in a contemporary cohort of patients with acute coronary syndromes (ACS) have not yet been elucidated [7]. Systematic review of available data in the literature showed plenty of case reports of WS with particular etiology (in-stent neoatherosclerosis [8], noncritical plaque coronary artery vasospasm [3,9], coronary vasospasm due to illicit drugs use [10], spontaneous coronary artery dissection [11], myocardial bridging [12], coronary fistulae [13], stress cardiomyopathy [14]), or atypical ECG and angiographic localization (inferior [15] or posterior [16] localization), but very few studies. The inventory of the studies published so far in are shown in The prevalence of Wellens' sign in patients with UA in the first study of de Zwaan and Wellens was 18% (26 of 145 patients) [5].…”

Entire process of electrocardiogram recording of Wellens syndrome: A case report

“…Previous studies have documented common etiologies of Wellens syndrome, including myocardial bridge[ 11 ], Tako-Tsubo cardiomyopathy[ 12 ], pulmonary embolus[ 13 ], and coronary spasm caused by drug abuse[ 14 ]. The pathophysiological mechanism underlying the characteristic T-wave changes in Wellens syndrome is debatable.…”

The relationship between myocardial bridge and frontal QRS‐T angle

“…Although the main angiographic finding of MB is narrowing of the coronary arteries during systole, it has been shown to persist during the diastole period. 1 , 13 , 14 Therefore, severe ischemia may be occurred in patients with MB. Increased heart rate due to different reasons can shorten the diastole time and increase the cardiac oxygen demand.…”