Wellens' syndrome

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
    • Shared characteristic ECG changes
      • T wave abnormality associated with critical LAD stenosis
  • 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
• Cocaine use may cause pseudo-Wellens due to vasospasm without critical stenosis

Differential Diagnosis

• High voltage
• PE
• RBBB
• Hypokalemia
• CNS Injury
• Persistent Juvenile T-wave pattern
• Digitalis Effect
• "Normal variant" STE with biphasic T-wave
  • 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

• Cardiac
  • ST-segment elevation myocardial infarction (STEMI)
  • Post-MI (ventricular aneurysm pattern)
  • Previous MI with recurrent ischemia in same area
  • Wellens' syndrome
  • Coronary artery vasospasm (eg, Prinzmetal's angina)
  • Coronary artery dissection
  • Pericarditis
  • Myocarditis
  • Aortic dissection in to coronary
  • Left ventricular aneurysm
  • Left ventricular pseudoaneurysm
  • Early repolarization
  • Left bundle branch block
  • Left ventricular hypertrophy (LVH)
  • Myocardial tumor
  • Myocardial trauma
  • RV pacing (appears as Left bundle branch block)
  • Brugada syndrome
  • Takotsubo cardiomyopathy
  • AVR ST elevation
• Other thoracic
  • Pneumomediastinum
  • Pneumothorax
  • Pulmonary embolism
• Metabolic
  • Drugs of abuse (eg, cocaine, crack, meth)
    • Cocaine chest pain
  • Hyperkalemia (only leads V1 and V2)
  • Hypothermia ("Osborn J waves")
• Medications
  • Tricyclic (TCA) toxicity
  • Digoxin

Evaluation

• History of chest pain
• Normal or slightly-elevated cardiac enzymes
• No precordial Q-waves
• Isoelectric or <1mm ST-segment elevation
• Wellens' pattern present in pain-free state

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

Note Wellens criteria should not be applied to patients with LVH

Management

• Urgent cardiac catheterization
• Stress testing contraindicated

Disposition

• Admit

See Also

• STEMI equivalents

External Links

Mattu ECG Case - Wellens' Syndrome

Video

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