ELECTROCARDIOGRAPHIC MANIFESTATIONS OF WELLENS' SYNDROME.

Rhinehardt J, et al. Am J Emerg Med 2002 Nov;20(7):638-43.

Wellens' syndrome is a pattern of electrocardiographic T-wave changes associated with critical, proximal left anterior descending (LAD) artery stenosis. The syndrome is also referred to as LAD coronary T-wave syndrome. Syndrome criteria include T-wave changes plus a history of anginal chest pain without serum marker abnormalities; patients lack Q waves and significant ST-segment elevation; such patients show normal precordial R-wave progression. The natural history of Wellens' syndrome is anterior wall acute myocardial infarction. The T-wave abnormalities are persistent and may remain in place for hours to weeks; the clinician likely will encounter these changes in the sensation-free patient. With definitive management of the stenosis, the changes resolve with normalization of the electrocardiogram. It is vital that the physician recognize these changes and the association with critical LAD obstruction and significant risk for anterior wall myocardial infarction.

COMMENT: Click here to view an EKG with Wellens’ syndrome. The criteria for Wellens' Syndrome include biphasic T waves in leads V2 and V3 (Type 1) or symmetric, often deeply inverted T waves in leads V2 and V3 (Type 2). These findings typically occur during pain-free intervals. It is highly specific for LAD lesions with 59% of patients in Wellens’ 1988 study having complete or near-complete occlusion. These patients are at high risk for extensive anterior wall myocardial infarction and/or sudden death. Early PCI or CABG is now recommended for these patients. Exercise stress tests are contraindicated in these patients due to suspected left main lesions.

CHARACTERISTIC ELECTROCARDIOGRAPHIC PATTERN INDICATING A CRITICAL STENOSIS HIGH IN LEFT ANTERIOR DESCENDING CORONARY ARTERY IN PATIENTS ADMITTED BECAUSE OF IMPENDING MYOCARDIAL INFARCTION.

de Zwaan C, Bar FW, Wellens HJ. Am Heart J 1982 Apr;103(4 Pt 2):730-6.

In patients admitted to the hospital because of unstable angina, a subgroup can be recognized that is at high risk for the development of an extensive anterior wall myocardial infarction. These patients, who show characteristic ST-T segment changes in the precordial leads on or shortly after admission, have a critical stenosis high in the left anterior descending coronary artery. Of 145 patients consecutively admitted because of unstable angina, 26 (18%) showing this ECG pattern, suggesting that this finding is not rare. In spite of symptom control by nitroglycerin and beta blockade, 12 of 16 patients (75%) who were not operated on developed a usually extensive anterior wall infarction within a few weeks after admission. In view of these observations, urgent coronary angiography and, when possible, coronary revascularization should be done in patients with unstable angina who show this ECG pattern.

ANGIOGRAPHIC AND CLINICAL CHARACTERISTICS OF PATIENTS WITH UNSTABLE ANGINA SHOWING AN ECG PATTERN INDICATING CRITICAL NARROWING OF THE PROXIMAL LAD CORONARY ARTERY.

de Zwaan C, et al. Am Heart J 1989 Mar;117(3):657-65.

One hundred eighty of 1260 patients consecutively admitted to the hospital because of unstable angina pectoris had the typical ST-T segment changes suggestive of a critical stenosis in the proximal LAD. In 108 patients the ECG abnormalities were present at the time of admission. In the remaining 72 patients they developed shortly thereafter. The difference between these two groups was a longer duration of anginal complaints in the former (mean 2.3 days). Results of coronary angiography, performed a mean of 4.6 days after the last attack of chest pain, showed 50% or more narrowing in the proximal LAD in all patients. Thirty-three patients had complete occlusion of the LAD and 75 had collateral circulation to the LAD. Results of left ventricular angiography showed abnormal systolic left ventricular wall motion in 137 patients and normal systolic motion in the remaining 43 patients. The difference between these two groups was a shorter mean time interval between the last attack of chest pain and angiography in the former group (p less than 0.001). Twenty-four patients had only abnormal diastolic wall motion. Twenty-one patients had a small increase in the creatine kinase level at the time of admission. Fifteen patients (nine before and six during early revascularization) had an anterior wall myocardial infarction in the hospital; these patients had a patent but severely narrowed LAD and a low incidence of collateral circulation to the LAD.