By Ken Grauer, MD
Today’s patient is a middle-aged man who presented to the emergency department (ED) with a history of chest pain with exertion during the past two weeks. His chest pain had been increasing and was at its most severe level the day he presented to the ED. The initial serum troponin level in the ED was more than 10,000 ng/L. Does the clinical scenario suggest Wellens’ syndrome?
Interpretation: One of the most commonly misunderstood electrocardiogram (ECG) entities is Wellens’ syndrome.
- First described in 1982, the objective of Wellens’ syndrome is to recognize a patient with a high-risk, proximal left anterior descending (LAD) artery — with a high possibility of progressing to total coronary occlusion with resultant extensive antero-lateral infarction.
- What the original investigators did not realize 40+ years ago was that the ECG findings consistent with Wellens’ syndrome represent spontaneous coronary reperfusion, which occurs after brief coronary occlusion has taken place. But the absence of infarction Q (or QS) waves, in association with no more than minimal ST elevation, and complete resolution of the patient’s chest pain indicate that, although there already has been coronary occlusion of the LAD coronary artery, the duration of such occlusion was brief — such that minimal myocardial necrosis occurred.
- In that setting, recognizing anterior lead ST segment coving and terminal T wave inversion (such as is seen in leads V3, V4, and V5 in today’s ECG) serves as a warning sign that timely cardiac catheterization is indicated, with a probable need for percutaneous coronary intervention and with the goal of preventing future infarction.
This is not what we see in today’s case.
- Today’s patient presents with increasing chest pain (whereas the diagnosis of Wellens’ syndrome can be made only if the patient had prior chest pain — but at the time of the ECG, the patient has no chest pain at all.
- Serum troponin exceeds 10,000 ng/L. This tells us that infarction has already taken place (i.e., it is too late to be Wellens’ syndrome, which occurs before a large infarction, not after it).
- There is loss of the r wave with a large QS complex in lead V3, which is an ECG indication that a large anterior infarction has already taken place.
For more information about this case, visit https://tinyurl.com/KG-Blog-453.
Ken Grauer, MD, is Professor Emeritus in Family Medicine, College of Medicine, University of Florida, Gainesville.
Today’s patient is a middle-aged man who presented to the emergency department (ED) with a history of chest pain with exertion during the past two weeks. His chest pain had been increasing and was at its most severe level the day he presented to the ED. The initial serum troponin level in the ED was more than 10,000 ng/L. Does the clinical scenario suggest Wellens’ syndrome?
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