Pseudo-Wellens syndrome from sepsis-induced cardiomyopathy: a case report and review of the literature

Urgent percutaneous coronary intervention in type 2 Wellens' syndrome: A case report of an atypical presentation in an elderly patient

Traditionally reflecting critical stenosis of the proximal left anterior descending (LAD) artery, Wellens' syndrome (WS) is an electrocardiogram (ECG) pattern of biphasic or deeply inverted T waves in leads V2 and V3. This critical stenosis can progress to an extensive anterior myocardial infarction (MI) if early and appropriate management is not received promptly. The diagnosis of severe stenosis of the LAD coronary artery can be made by using electrocardiographic changes in Wellens' syndrome. Due to the significant area that the LAD vascularizes, patients who exhibit symptoms and test results suggestive of this syndrome should be referred right away for an angiographic exploration in order to confirm the diagnosis and guide treatment. We report a case of a 71-year-old male admitted to our department for acute chest pain. His ECG showed Wellens' syndrome type 2 during both chest pain and pain free with slightly elevated troponin. His TIMI score was 3 and the GRACE score was 136. Critical stenosis of the LAD coronary artery was found in the coronary angiography, which required a drug-eluting stent. The patient was discharged asymptomatic from medical therapy. The diagnosis was established on the basis of the patient's interview, ECG analysis, and coronary angiography.

ST segment and T wave abnormalities: A narrative review

INTRODUCTION

The electrocardiogram (ECG) is a valuable tool for interpreting ventricular repolarization. This article aims to broaden the diagnostic scope beyond the conventional ischemia-centric approach, integrating an understanding of pathophisiological influences on ST-T wave changes.

METHODS

A review was conducted on the physiological underpinnings of ventricular repolarization and the pathophisiological processes that can change ECG patterns. The research encompassed primary repolarization abnormalities due to uniform variations in ventricular action potential, secondary changes from electrical or mechanical alterations, and non-ischemic conditions influencing ST-T segments.

RESULTS

Primary T waves are characterized by symmetrical waves with broad bases and variable QT intervals, indicative of direct myocardial action potential modifications due to ischemia, electrolyte imbalances, and channelopathies. Secondary T waves are asymmetric and often unassociated with significant QT interval changes, suggesting depolarization alterations or changes in cardiac geometry and contractility.

CONCLUSION

We advocate for a unified ECG analysis, recognizing primary and secondary ST-T changes, and their clinical implications. Our proposed analytical framework enhances the clinician's ability to discern a wide array of cardiac conditions, extending diagnostic accuracy beyond myocardial ischemia.

Left Anterior Descending Coronary T-wave Inversion Pattern (Wellens' Syndrome) Associated with Myopericarditis and a Normal Left Coronary Artery

Background

Wellens' syndrome is characterised by a history of chest pain with an abnormal electrocardiogram (EKG), demonstrating biphasic or deeply inverted T waves in leads V2-3 (may extend to involve all precordial and lateral limb leads - the type B Wellens' pattern). A Wellens' EKG pattern is considered highly specific for critical stenosis involving the ostial/proximal left anterior descending artery (LAD). However, there are no reported cases of an association of a Wellens' EKG pattern with myopericarditis. Here, we present such a rare case.

Case description

A thirty-one-year-old female with known essential hypertension and psoriatic arthritis presented with a constant, central chest pain radiating to the shoulders and back. The patient's physical examination was unremarkable at presentation other than elevated blood pressure at 170/68 mmHg. An EKG at presentation demonstrated deep symmetric T-wave inversions in anterolateral leads with elevated high-sensitivity troponin, and an elevated erythrocyte sedimentation rate. The patient was referred to the cardiac catheterisation laboratory for concerns of a Wellens' EKG pattern; however, invasive angiography demonstrated only obtuse marginal branch disease - no LAD disease was noted. Cardiac magnetic resonance (CMR) imaging confirmed the diagnosis of myopericarditis and absence of myocardial infarction. The patient was medically managed and discharged home in a stable condition.

Conclusion

In literature and established clinical practice, the Wellens' EKG pattern is considered highly concerning for critical ostial/proximal LAD stenosis. However, we now propose that myopericarditis may be considered in a differential diagnosis for this EKG pattern.

LEARNING POINTS

Wellens' syndrome is characterised by a history of chest pain with an abnormal electrocardiogram (EKG), demonstrating biphasic or deeply inverted T waves in leads V2-3.A Wellens' EKG pattern is considered highly specific for critical stenosis involving the ostial/proximal left anterior descending artery (LAD).Association of Wellens' pattern EKG has been described in association with various other pathologies; however, its association with acute myopericarditis has not been well described.

Acute coronary syndrome versus cardiac memory: Unexpected cause of Pseudo-Wellens syndrome

Pseudo-Wellens Syndrome (PWS) refers to absence of severe obstructive lesion in the proximal segment of the left anterior descending (LAD) despite having clinical and electrocardiography (ECG) features similar to Wellens Syndrome (WS). In previous reports, PWS most commonly caused by illicit drug use, stress cardiomyopathy, or unknown etiologies In this report, we aimed to present our case in which we detected the development of "memory T wave" secondary to Paroxysmal Supraventricular Tachycardia (PSVT) episodes as an interesting cause of PWS that has not been reported before.

Wellens pattern as the debut of acute pulmonary embolism: A case report

The Wellens pattern is an electrocardiographic finding seen in patients with chest pain and atherosclerotic coronary artery disease and is described as a symmetrical T-wave inversion or biphasic T-wave inversion in precordial leads. The deep inversion of the precordial T wave is a sign associated with various etiologies, including left ventricular hypertrophy, vasospasm, and pulmonary embolism. We present the case of a patient who debuts with chest pain and electrocardiographic findings consistent with the Wellens and McGinn-White patterns, who was subsequently diagnosed with intermediate-risk pulmonary embolism after ruling out obstructive coronary artery disease. We discussed the differential diagnostic approach to T-wave inversion as a sign associated with high-risk conditions.

Wellens' syndrome following severe COVID-19 infection, an innocent coincidence or a deadly association: two case reports

BACKGROUND

Coronavirus disease 2019 (COVID-19) has been associated with late-onset cardiovascular complications primarily due to a hypercoagulable state. Its association with Wellens' syndrome, which reflects a stenosis in the proximal left anterior descending coronary artery, is not well established. We present two cases diagnosed with this syndrome following their COVID-19 acute phase despite taking adequate anticoagulation.

CASE PRESENTATION

We present two patients with incidental electrocardiography (ECG) showing the typical Wellens'-related changes, with an underlying severe triple-vessel coronary artery disease a few weeks following a severe COVID-19 infection associated with high inflammatory markers. The stenotic lesions were diagnosed by cardiac catheterization, and both patients underwent Coronary Artery Bypass Grafting successfully. Notably, patients' baseline ECGs were normal, and they were maintained on Rivaroxaban 10 mg following their viral illness.

CONCLUSION

Despite advances in the preventive measures for COVID-19 complications, its pathophysiologic impact on vasculature and atherosclerosis is still incompletely understood. Further clinical trials must be conducted to study this association between Wellens' syndrome and this virus to prevent life-threatening complications.