Wellens' Syndrome – Report of two cases

Abstract

Wellens' Syndrome is a pattern of electrocardiographic T-wave changes associated with critical, proximal left anterior descending (LAD) artery stenosis. Diagnostic criteria of Wellens' Syndrome are history of chest pain, little or no cardiac enzyme elevation, little or no ST-segment elevation, no loss of precordial R waves, no pathologic precordial Q waves and typical T-wave changes. Urgent cardiac catheterization is vital to prevent myocardial necrosis. Here we are presenting two cases with Wellens' Syndrome who had been sent for catheterization before marked myocardial infarction developed.The first case was 63 years old woman admitted to emergency room with a typical chest pain lasting for 7 h. Electrocardiography (ECG) revealed characteristic Type A Wellens' Syndrome. The second case was also a 64 years old female patient. She was admitted to emergency room with a chest pain lasting for 2 days. Type B Wellens' Syndrome was considered according to ECG and clinical findings. Emergency angiography revealed critical LAD occlusions which were resolved before marked MI occurred in both of the cases.It is important for the emergency physicians, to recognize the typical ECG findings of Wellens' Syndrome, because these characteristic ECG findings are considered as a marker for critical LAD occlusions.

Atypical Presentation of Acute Coronary Syndrome and Importance of Wellens’ Syndrome

“…The differential diagnoses of T wave inversions are acute coronary syndrome (ACS), pulmonary embolism, myocarditis, left ventricular hypertrophy, juvenile T wave, Wolf-Parkinson-White syndrome, and digoxin toxicity [ 14 ]. Unlike the regular practice in patients with possible ischemic chest pains, cardiac stress testing is contraindicated in Wellens’ syndrome patients because it can precipitate acute myocardial infarction [ 9 ].…”

Case Report: Diffuse T wave inversions as initial electrocardiographic evidence in acute pulmonary embolism

“…Given a background of significant cardiovascular risk factors, a coronary event was thought more likely. Deep T wave inversions on the precordial leads were concerning for Wellen’s syndrome 7 . The clues to possible acute PE in our case was the transient desaturation that occurred during cardiac catheterization and the observed change on repeat EKG.…”

Síndrome de Wellens. Reporte y revisión de un caso

“…The incidence of WS is 10-15% of all acute coronary syndromes 17 with an etiology similar to any other condition that causes coronary heart disease: atherosclerotic plaque, coronary arterial vasospasm, hypoxia, and increased cardiac demand. Its risk factors include a family history of premature coronary heart disease, type II diabetes mellitus, metabolic syndrome, hypertension, smoking, hyperlipidemia, work stress, advanced age 18 (55 ± 9 years), cases associated with HIV, probably due to premature coronary disease 19 and also in patients without cardiovascular risk factors.…”

“…Type B is the most common and least specific, 9 represents 76% of cases and is characterized by symmetrical and deep inverted T waves in V1 to V4. 17 Schears MR and collaborators, describe the evolution of these patterns starting with biphasic T waves (pattern A) that are deeply and symmetrically reversed (pattern B). Then it extends to V4, then to V5 and finally to V6, not documented in all cases by lack of serial electrocardiograms, 21 without defining the time in which one pattern can change to another.…”

“…Atypical cases have been described where the type B pattern changes to type A. 22 It should be emphasized that changes in the T wave occur during periods without precordial pain and pseudo normalized during the precordial pain episode, and may persist for hours or weeks 7,23 leading to errors in diagnosis and inadequate risk stratification, so the ability to recognize these patterns is extremely important, since ECG changes can be subtle [8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24] There are atypical presentations in which there is no precordial pain, only syncope, but the electrocardiographic pattern meets WS criteria. 25 In the case presented, the fact that the patient was asymptomatic at the time of admission to the emergency department, and the taking of an initial electrocardiogram as part of the cardiology evaluation, showed the inversion of T waves in precordial leads from V2 to V6, leading to timely diagnosis confirming it with pseudonormalization during an episode of precordial pain, which occurred spontaneously without maneuvers to cause ischemia.…”