Wellens' syndrome: Difference between revisions

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==Background==
==Background==
*T wave abnormality that is associated with critical LAD stenosis
*First described in 1982
**Finding can be transient (persists for hours after pain has resolved and then disappears)
**Subset of patients fared poorly with medical management of “impending myocardial infarction” ([[unstable angina]])
**Preinfarction stage of CAD, and heralds extensive anterior wall MI
***At risk for extensive anterior wall myocardial infarction due to proximal LAD stenosis<ref>de Zwaan C, Bär FW, Wellens HJ. Characteristic electrocardiographic pattern indicating a critical stenosis high in left anterior descending coronary artery in patients admitted because of impending myocardial infarction. Am Heart J. 1982;103(4 Pt 2):730-736.</ref>
***Shared characteristic ECG changes
****T wave abnormality associated with critical LAD stenosis<ref>Rhinehardt J, Brady WJ, Perron AD, Mattu A. Electrocardiographic manifestations of Wellens' syndrome. American Journal of Emergency Medicine. 2002;20(7):638-643. doi:10.1053/ajem.2002.34800.</ref>
**Findings can be transient (persists for hours after pain has resolved and then disappears)


== Criteria ==
==Clinical Features==
*Symptoms of [[Myocardial infarction]] or ischemia
*Symptoms have often resolved at presentation
*May have previous recent episodes of [[angina]] or anginal equivalents
*Initial cardiac enzymes are frequently normal or slightly elevated<ref>Ünlüer EE et al. Red Flags in Electrocardiogram for Emergency Physicians: Remembering Wellens' Syndrome and Upright T wave in V1. West J Emerg Med. 2012 May; 13(2): 160–162.</ref><ref>Kannan L and Figueredo VM. Wellens' Syndrome. Jan 1, 2015. N Engl J Med 372;1.</ref>
*[[Cocaine]] use may cause pseudo-Wellens due to vasospasm without critical stenosis<ref>Dhawan SS. Pseudo-Wellens’ syndrome after crack cocaine use. Can J Cardiol. 2008; 24(5):404.</ref>


#Biphasic T waves in leads V2-V3 OR symmetric, often deeply inverted T waves in V2-V3
==Differential Diagnosis==
#Prior history of chest pain (CP resolved)
*High voltage
#Little or no cardiac enzyme elevation
*[[PE]]
#No pathologic precordial Q waves
*[[ECG (Basics)|RBBB]]
#Little or no ST-segment elevation  
*[[Hypokalemia]]
#No loss of precordial R waves
*[[head injury|CNS Injury]]
*Persistent Juvenile T-wave pattern
*[[Digitalis Effect]]
*"Normal variant" STE with biphasic T-wave<ref>Wang, et al. ST-segment elevation in conditions other than acute myocardial infarction. NEJM 2003, 349:2128-2135.</ref>
**Common in young, healthy, Black males
**Patterns that are NOT found in Wellen's
***High voltage complexes
***Notching at J-point ("fishhook")
***Concave upward ST segment followed by steep drop in T wave
{{ST elevation DDX}}


Two T-wave Characteristics:
==Evaluation==
*History of [[chest pain]]
*Normal or slightly-elevated [[cardiac enzymes]]
*No precordial Q-waves
*Isoelectric or <1mm [[ST elevation|ST-segment elevation]]
*Wellens' pattern present in pain-free state


*A: Biphasic pattern - 75% - Deeply inverted and symmetric T-waves
Two T-wave Characteristics (at times terms are reversed in the literature or labeled Type I and II):
*B: Inversion pattern - 25% - Biphasic T-waves (initial + deflection and terminal - deflection)
*Type A (25%)
**Biphasic T-wave in V2/V3
*Type B (75%)
**Deep, symmetrically inverted T-waves in V2/V3


[[Image:Wellens.jpg]]  
[[Image:Wellens.png]]  


''Note Wellens criteria should not be diagnosed in a patetient with LVH.&nbsp;''
''Note Wellens criteria should not be applied to  patients with [[LVH]]''


==Treatment==
==Management==
#Urgent cardiac catheterization
*Urgent cardiac catheterization
Stress testing contraindicated, may prove fatal
*Stress testing contraindicated


==Source==
==Disposition==
Wellens’ Syndrome. Annals of Emergency Medicine, March, 1999
*Admit


[[Category:Cards]]
==See Also==
*[[STEMI equivalents]]
 
==External Links==
[https://www.youtube.com/watch?v=RdnwIWu5HHg Mattu ECG Case - Wellens' Syndrome]
 
==Video==
{{#widget:YouTube|id=SgTJYu8b6dE}}
 
==References==
<references/>
 
[[Category:Cardiology]]

Revision as of 19:06, 26 September 2019

Background

  • First described in 1982
    • Subset of patients fared poorly with medical management of “impending myocardial infarction” (unstable angina)
      • At risk for extensive anterior wall myocardial infarction due to proximal LAD stenosis[1]
      • Shared characteristic ECG changes
        • T wave abnormality associated with critical LAD stenosis[2]
    • Findings can be transient (persists for hours after pain has resolved and then disappears)

Clinical Features

  • Symptoms of Myocardial infarction or ischemia
  • Symptoms have often resolved at presentation
  • May have previous recent episodes of angina or anginal equivalents
  • Initial cardiac enzymes are frequently normal or slightly elevated[3][4]
  • Cocaine use may cause pseudo-Wellens due to vasospasm without critical stenosis[5]

Differential Diagnosis

  • High voltage
  • PE
  • RBBB
  • Hypokalemia
  • CNS Injury
  • Persistent Juvenile T-wave pattern
  • Digitalis Effect
  • "Normal variant" STE with biphasic T-wave[6]
    • Common in young, healthy, Black males
    • Patterns that are NOT found in Wellen's
      • High voltage complexes
      • Notching at J-point ("fishhook")
      • Concave upward ST segment followed by steep drop in T wave

ST Elevation

Evaluation

Two T-wave Characteristics (at times terms are reversed in the literature or labeled Type I and II):

  • Type A (25%)
    • Biphasic T-wave in V2/V3
  • Type B (75%)
    • Deep, symmetrically inverted T-waves in V2/V3

Wellens.png

Note Wellens criteria should not be applied to patients with LVH

Management

  • Urgent cardiac catheterization
  • Stress testing contraindicated

Disposition

  • Admit

See Also

External Links

Mattu ECG Case - Wellens' Syndrome

Video

{{#widget:YouTube|id=SgTJYu8b6dE}}

References

  1. ↑ de Zwaan C, Bär FW, Wellens HJ. Characteristic electrocardiographic pattern indicating a critical stenosis high in left anterior descending coronary artery in patients admitted because of impending myocardial infarction. Am Heart J. 1982;103(4 Pt 2):730-736.
  2. ↑ Rhinehardt J, Brady WJ, Perron AD, Mattu A. Electrocardiographic manifestations of Wellens' syndrome. American Journal of Emergency Medicine. 2002;20(7):638-643. doi:10.1053/ajem.2002.34800.
  3. ↑ Ünlüer EE et al. Red Flags in Electrocardiogram for Emergency Physicians: Remembering Wellens' Syndrome and Upright T wave in V1. West J Emerg Med. 2012 May; 13(2): 160–162.
  4. ↑ Kannan L and Figueredo VM. Wellens' Syndrome. Jan 1, 2015. N Engl J Med 372;1.
  5. ↑ Dhawan SS. Pseudo-Wellens’ syndrome after crack cocaine use. Can J Cardiol. 2008; 24(5):404.
  6. ↑ Wang, et al. ST-segment elevation in conditions other than acute myocardial infarction. NEJM 2003, 349:2128-2135.
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