Wellens' syndrome or inverted U-waves?

Navigating Diagnostic Challenges in Acute Coronary Syndrome: A Case of Bezold-Jarisch Reflex and Wellens Pattern

Acute coronary syndrome (ACS) presents significant diagnostic challenges, particularly in cases with atypical presentations and complex clinical scenarios. Here, we describe the case of a 59-year-old man who presented with presyncope, bradycardia, hypotension, and later syncope, attributed to the Bezold-Jarisch reflex. Electrocardiographic findings suggested both inferior and anterior wall infarction, with dynamic changes in T-wave morphology further complicating the diagnostic process. Despite a type A Wellens' pattern indicating critical stenosis in the proximal left anterior descending (LAD) artery, coronary angiography revealed a complete thrombotic lesion in the proximal right coronary artery (RCA), necessitating urgent intervention. Despite the Wellens pattern indicating LAD involvement, RCA revascularization took precedence due to immediate thrombotic risk. This case underscores the diagnostic challenges associated with conflicting clinical manifestations in ACS and highlights the importance of individualized management strategies integrating advanced diagnostic modalities to optimize outcomes. Understanding the interplay of complex clinical presentations and employing a nuanced approach to management are crucial in effectively navigating ACS scenarios.

ECG patterns suggestive of high-risk coronary anatomy in non-ST-segment elevation acute coronary syndrome - an analysis of real-world patients

Introduction

Electrocardiographic (ECG) patterns suggestive of high-risk coronary anatomy are indications for an urgent invasive approach in non-ST-segment elevation acute coronary syndrome (NSTE-ACS).

Aim

To estimate the frequency of the observed phenomenon and assess the clinical characteristics of NSTE-ACS subjects associated with Wellens syndrome, the de Winter sign, or ST-segment depressions by ≥ 1 mm in ≥ 6 classic ECG leads with simultaneous ST-segment elevation in aVR and/or V1.

Material and methods

Out of 207 pre-screened subjects diagnosed with NSTE-ACS, 64 patients (26 women and 38 men) with complete medical records (including admission ECG and coronary angiography during the index hospitalization), and significant culprit stenosis or occlusion of the left main coronary artery (LMCA) or the proximal/middle segment of the left anterior descending artery (LAD) entered the final analysis. Clinical characteristics of patients exhibiting any of the high-risk ECG patterns was compared to their counterparts with significant lesions in LMCA or proximal/middle LAD without any of the high-risk ECG patterns.

Results

Among 64 patients with significant culprit lesions in LMCA or LAD, 19 (29.69%) exhibited one of the high-risk ECG patterns: Wellens syndrome (n = 10), the de Winter sign (n = 0), or multiple ST-segment depressions (n = 9). Clinical characteristics were comparable in 19 NSTE-ACS patients with the high-risk ECG patterns and their 45 counterparts.

Conclusions

Because ECG patterns suggestive of high-risk coronary anatomy are relatively frequent in patients with NSTE-ACS and culprit lesions in LMCA or LAD, their early recognition is of clinical importance.

A Case of Wellens Syndrome in a Young Adult With Intermittent Chest Pain: Understanding the Unique Pattern and Clinical Correlation

Wellens syndrome is a unique electrocardiographic (ECG) pattern usually suggestive of critical stenosis of the left anterior descending (LAD) coronary artery. Providers must recognize this pattern as it frequently occurs in symptom-free periods and represents a pre-infarction stage requiring early intervention. We present the case of a 39-year-old male with a past medical history of hypertension who was brought to the emergency department due to complaints of worsening recurrent intermittent squeezing left-sided chest pain of two months duration. Cardiac enzymes were within limits. ECG done at triage was significant for biphasic T waves in leads V2-V5 consistent with type A Wellens syndrome. The cardiology team consulted, with the patient subsequently having a percutaneous coronary intervention to the mid and proximal portion of the LAD. The patient was later discharged on the third day of admission on guideline-directed medical therapy, with plans to follow up closely with the cardiology clinic. This case highlights the significance of using the characteristics pattern of Wellens syndrome in providing critical diagnostic and prognostic value. This article aimed to promote awareness of Wellens syndrome, the clinical correlation, and the role of timely acute management.

Wellens Syndrome Electrocardiogram Pattern in a Patient With Multi-Vessel Coronary Artery Disease

Wellens syndrome is an electrocardiogram (ECG) pattern associated with critical stenosis of the proximal left anterior descending (LAD) artery. In patients with Wellens syndrome, characteristic biphasic or inverted T waves are seen on ECG. This case report presents a 48-year-old male admitted for chest pain and shortness of breath who was found to have a Wellens syndrome ECG pattern. Oddly, cardiac catheterization revealed multi-vessel coronary artery disease, and critical proximal LAD artery stenosis was not appreciated. Ultimately, the patient was treated with coronary artery bypass graft (CABG) surgery and later discharged in stable condition.

A Case of Wellens Syndrome in a 30-Year-Old Woman From Sub-Saharan Africa: A Perplexing Clinical Entity With Invaluable Lessons

With an estimated contribution of up to 6% of all acute coronary events, young adults are experiencing an escalating burden and mortality attributable to coronary artery disease (CAD) worldwide. Wellens syndrome, a preinfarction clinical entity with distinctive electrocardiographic (ECG) features and high propensity for extensive anterior wall infarctions, affects about 15% of unstable angina subpopulation. We report challenges and lessons learnt from the first ever documented case of Wellens syndrome in Tanzania. A 30-year-old female of African descent was referred to us from an upcountry zonal referral hospital for etiological determination of chest pain and expert management. Her medical history was unremarkable, and she had no apparent risk factors for CAD. She presented with a 7-day history of ongoing sharp central chest pain that was radiating to the neck and jaws and relieved momentarily by morphine. She had stable vitals with an unremarkable systemic examination; however, a 12-lead ECG revealed deeply inverted T-waves on leads V2 through V4. Based on our extensive history and physical examination we came up with a diagnosis of type B Wellens syndrome with impending anterior wall myocardial infarction. She underwent cardiac catheterization that revealed a nonthrombogenic severe subocclusive (>95%) mid left anterior descending artery stenosis. Subsequently, angioplasty was performed successfully with a resolute integrity stent, and TIMI III flow was achieved. To conclude, despite its relative frequency, physicians’ awareness of Wellens syndrome pathognomonic ECG features is of paramount importance to curb its attributable morbidity and mortality.

Pseudo-Wellens' syndrome in pulmonary embolism

Wellens' syndrome is described as characteristic biphasic or symmetrical T-wave inversion with normal precordial R-wave progression and the absence of Q waves in the right precordial leads. It is seen during chest pain-free interval in a subset of patients with unstable angina. Wellens' syndrome is associated with critical stenosis of proximal left anterior descending (LAD) coronary artery. Similar characteristic ECG changes associated with causes other than LAD stenosis have been described as pseudo-Wellens' syndrome. In this case report, we present a young 22-year-old man who presented with characteristic Wellens' ECG changes in the setting of pulmonary embolism with right ventricular strain. T-wave inversion in right precordial leads is a well-recognised ECG manifestation of right ventricular strain; however, biphasic T waves in the setting of pulmonary embolism are rare. Pulmonary embolism was seen in our patient a week after starting risperidone. There is a reported association between antipsychotic drugs and increased risk of thromboembolism. Risperidone could have potentially contributed to the pulmonary embolism in our patient given the temporal association and absence of risk factors.

Pitfalls in Electrocardiographic Diagnosis of Acute Coronary Syndrome in Low-Risk Chest Pain

Less than half of patients with a chest pain history indicative of acute coronary syndrome have a diagnostic electrocardiogram (ECG) on initial presentation to the emergency department. The physician must dissect the ECG for elusive, but perilous, characteristics that are often missed by machine analysis. ST depression is interpreted and often suggestive of ischemia; however, when exclusive to leads V1–V3 with concomitant tall R waves and upright T waves, a posterior infarction should first and foremost be suspected. Likewise, diffuse ST depression with elevation in aVR should raise concern for left main- or triple-vessel disease and, as with the aforementioned, these ECG findings are grounds for acute reperfusion therapy. Even in isolation, certain electrocardiographic findings can suggest danger. Such is true of the lone T-wave inversion in aVL, known to precede an inferior myocardial infarction. Similarly, something as ordinary as an upright and tall T wave or a biphasic T wave can be the only marker of ischemia. ECG abnormalities, however subtle, should give pause and merit careful inspection since misinterpretation occurs in 20–40% of misdiagnosed myocardial infarctions.

A Silent Alarm at Occupational Evaluation Two Months after a Normal Painful ECG: A Case of Wellens’ syndrome

We describe a case of a 42-year-old man, with a previous episode of angina and a normal ECG and serum cardiac markers, and a two months later finding of biphasic T wave in leads V2-V3 and deeply inverted T wave in V4-V5 at a asymptomatic occupational evaluation. This is a typical ECG pattern of Wellens' syndrome. A subsequent coronary angiography showed a critical stenosis of proximal left anterior descendent. We underline the careful value of prolonged observation in chest pain unit and repetitive ECG evaluation also during pain-free period after an angina episode, to exclude an earlier T wave pseudonormalization.

ST-Elevation Myocardial Infarction after Pharmacologic Persantine Stress Test in a Patient with Wellens' Syndrome

Wellens' syndrome, also known as LAD coronary T-wave inversion syndrome, is a characteristic ECG pattern that highly suggests critical stenosis of the proximal left anterior descending (LAD) coronary artery. 75% of patients with this finding go on to develop acute anterior wall myocardial infarction within one week unless prevented by early intervention on the culprit lesion. Most instances of ST-elevation occurring during cardiac stress testing have been observed with exercise, with only seven cases reported in the literature with pharmacologic stress. We present a case of a patient with no known cardiac disease who presented with chest pain and an ECG consistent with Wellens' syndrome that developed an acute anterior wall ST-elevation myocardial infarction after pharmacologic stress test.

Wellens' syndrome: a classical electrocardiographic sign of impending myocardial infarction

We describe a case of previously healthy 72-year-old man, who presented with rest angina. The ECG revealed sinus rhythm, biphasic T waves with preserved R waves in V1-V4 precordial leads. Subsequent evaluation revealed the normal serum cardiac marker levels and echocardiography with the coronary angiography showing a critical lesion in the proximal left anterior descending artery. Thus it was diagnosed as Wellens' syndrome. In our case, we highlight the subtle though classical ECG findings of Wellens' syndrome and its specific angiographic correlation. It can be of vital importance to identify these changes and intervene in time appropriately so as to avoid the development of myocardial infarction that carries a substantial morbidity and mortality. Important aspects of diagnosis and management have also been reviewed.

Wellen's syndrome: An ominous EKG pattern

Wellen's syndrome is a characteristic T-wave on an electrocardiogram during a pain-free period in a patient with intermittent chest pain. This finding suggests a high-degree stenosis of the proximal left anterior descending (LAD) coronary artery that will soon result in an acute anterior wall myocardial infarction (MI) if the patient is not urgently catheterized and the occlusion opened. This case report discusses a young male patient with no known cardiac disease with an EKG that demonstrates the classic Wellen's T-waves. He was urgently taken to cardiac catheterization and his 95% proximal LAD stenosis was reduced via drug-eluding stent. Through knowledge of Wellen's T-waves, more anterior wall MIs can be prevented.

Diagnostic Value of Electrocardiographic T Wave Inversion in Lead aVL in Diagnosing Coronary Artery Disease in Patients with Chronic Stable Angina

OBJECTIVES

The clinical value of T wave inversion in lead aVL in diagnosing coronary artery disease (CAD) remains unclear. This study aims to investigate the correlation between aVL T wave inversion and CAD in patients with chronic stable angina.

METHODS

Electrocardiograms (ECGs) of 257 consecutive patients undergoing coronary angiography were analyzed. All patients had chronic stable angina. All patients with secondary T wave inversion had been excluded (66 patients). The remaining 191 patients constituted the study population. Detailed ECG interpretation and coronary angiographic findings were conducted by experienced cardiologists.

RESULTS

T wave inversion in aVL was identified in 89 ECGs (46.8%) with definite ischemic Q-ST-T changes in different leads in 97 ECGs (50.8%). Stand alone aVL T wave inversion was found in 27 ECGs (14.1%) while ischemic changes in other leads with normal aVL were identified in 36 ECGs (18.8%). The incidence of CAD was 86.3%. Single, two- and multi-vessel CAD were found in 38.8%, 28.5% and 32.7% of cases respectively. The prevalence of left main, left anterior descending, left circumflex and right coronary arteries were 4.7%, 61.2%, 29.3% and 44.5%, respectively. T wave inversion in aVL was found to be the only ECG variable significantly predicting mid segment left anterior descending artery (LAD) lesions (Odds Ratio 2.93, 95% Confidence Interval 1.59-5.37, p=0.001).

CONCLUSION

This study provides new information relating to T wave inversion in lead aVL to mid segment LAD lesions. Implication of this simple finding may help in bedside diagnosis of CAD typically mid LAD lesions. However, further studies are needed to corroborate this finding.