Hello Friends
• Recently I came across an article on an ECG pattern named Wellens T wave changes. I don’t know about you people. But this is the first time I have come across this syndrome. Wellens’ syndrome is a pattern of deeply inverted or biphasic T waves in V2-3, which is highly specific for a critical stenosis of the left anterior descending artery (LAD).
• Patients may be pain free by the time the ECG is taken and have normally or minimally elevated cardiac enzymes; however, they are at extremely high risk for extensive anterior wall MI within the next few days to weeks.
• Due to the critical LAD stenosis, these patients usually require invasive therapy, do poorly with medical management and may suffer MI or cardiac arrest if inappropriately stress tested.
Diagnostic Criteria
Rhinehart et al (2002) describe the following diagnostic criteria for Wellens’ syndrome:
• Deeply-inverted or biphasic T waves in V2-3 (may extend to V1-6)
• Isoelectric or minimally-elevated ST segment (< 1mm) • No precordial Q waves • Preserved precordial R wave progression • Recent history of angina • ECG pattern present in pain-free state • Normal or slightly elevated serum cardiac markers There are two patterns of T-wave abnormality in Wellens’ syndrome: • Type A = Biphasic, with initial positivity & terminal negativity (25% of cases) • Type B = Deeply and symmetrically inverted (75% of cases) The T waves evolve over time from from a Type A to a Type B pattern (see an example of this here). Biphasic T Waves (Type A) Deeply Inverted T Waves (Type B) The following sequence of events is thought to occur in patients with Wellens’ syndrome: 1. A sudden occlusion of the LAD, causing a transient anterior STEMI. The patient has chest pain & diaphoresis. This stage may not be successfully captured on an ECG recording. 2. Re-perfusion of the LAD (e.g. due to spontaneous clot lysis or prehospital aspirin). The chest pain resolves. ST elevation improves and T waves become biphasic or inverted. The T wave morphology is identical to patients who reperfuse after a successful PCI. 3. If the artery remains open, the T waves evolve over time from biphasic to deeply inverted. 4. The coronary perfusion is unstable, however, and the LAD can re-occlude at any time. If this happens, the first sign on the ECG is an apparent normalisation of the T waves — so-called “pseudo-normalisation”. The T waves switch from biphasic/inverted to upright and prominent. This is a sign of hyperacute STEMI and is usually accompanied by recurrence of chest pain, although the ECG changes can precede the symptoms. 5. If the artery remains occluded, the patient now develops an evolving anterior STEMI Please see the attachments. From Nos. 1 to 4 for the above texts Now I want you to read my article in our forum with title of ‘A case from the past’, under Cardiothoracic Medicine and Surgery, dated 11th December 2013. In that article I had mentioned about a patient who came to me with uneasiness and whose ECG showed a pattern which I have attached with no. 5 and 6 and who subsequently died at home despite my advice to get admitted in ICU. I think the ECG which I have shown almost same pattern as the one shown above. Is it not? Truly at that time of the event, I have not heard about this syndrome at all and so I was not aware of the significance of this syndrome. But in the given background of the clinical picture, with that subtle change in the ECG pattern something prompted me that I should be careful with this person and hence I forced him to get admitted. But as ill luck would have it, fate decided otherwise. Retrospectively now I think even if he got admitted, it is doubtful whether he would have survived with available facility here at that time. UA Mohammed