Prevalence and Clinical Implication of Wellens' Sign in Patients With Non-ST-Segment Elevation Myocardial Infarction

Lessons in clinical reasoning - pitfalls, myths, and pearls: a case of crushing, substernal chest pain

OBJECTIVES

Diagnostic error is not uncommon and diagnostic accuracy can be improved with the use of problem representation, pre-test probability, and Bayesian analysis for improved clinical reasoning.

CASE PRESENTATION

A 48-year-old female presented as a transfer from another Emergency Department (ED) to our ED with crushing, substernal pain associated with dyspnea, diaphoresis, nausea, and a tingling sensation down both arms with radiation to the back and neck. Troponins were elevated along with an abnormal electrocardiogram. A negative myocardial perfusion scan led to the patient's discharge. The patient presented to the ED 10 days later with an anterior ST-elevation myocardial infarction.

CONCLUSIONS

An overemphasis on a single testing modality led to diagnostic error and a severe event. The use of pre-test probabilities guided by history-taking can lead to improved interpretation of test results, ultimately improving diagnostic accuracy and preventing serious medical errors.

Wellens syndrome: An important consideration in patients with chest pain

ABSTRACT

Coronary artery disease (CAD) is the number one cause of death in the United States, and it is estimated that every 40 seconds one person experiences a heart attack. Among patients with chronic CAD, many will experience a potentially fatal complication known as acute coronary syndrome (ACS). Wellens syndrome is a rare form of ACS that indicates critical left anterior descending coronary artery occlusion and can be identified by its characteristic T-wave patterns on ECG. This syndrome also may go unrecognized by clinicians because of a lack of familiarity with the ECG findings. This article describes the Wellens ECG pattern and its significance in patients with chest pain.

Characteristics of Wellens' Syndrome in the Current PCI Era: A Single-Center Retrospective Study

Objectives

The goal of this retrospective study was to reveal the prevalence, angiographic characteristics, clinical presentation, and long-term outcomes of non-ST-segment elevation myocardial infarction (NSTEMI) patients with Wellens' syndrome.

Background

Procedural results for percutaneous coronary intervention (PCI) in acute coronary syndrome (ACS) have improved in recent years. However, there is still a paucity of available clinical trial data for Wellens' syndrome even though it is a well-known high-risk ACS.

Methods

Among a total of 3528 patients with ACS who underwent angioplasty from 2017 to 2019 at the Cardiovascular Center of Beijing Friendship Hospital, 476 NSTEMI patients with culprit left anterior descending (LAD) vessels were enrolled in this study. According to electrocardiographic criteria of Wellens' syndrome, the patients were divided into a Wellens group (n = 138) and a non-Wellens group (n = 338). The primary endpoint was cardiac death; the secondary endpoints were main adverse cardiovascular and cerebrovascular events (MACCEs), a composite of all-cause death, cardiac death, heart failure, target lesion revascularization, recurrent myocardial infarction, and stroke. All of the medical and follow-up data were obtained from our institutional database.

Results

The incidence of Wellens' syndrome in all ACS patients was 5.7% (200 of 3528). Among the 200 patients with Wellens' syndrome, 138 had NSTEMI, for a proportion of 69%. There was a significant decrease in the percentage of preexisting coronary heart disease (CHD), prior myocardial infarction, and previous PCI (P < 0.05) in the Wellens group compared with the non-Wellens group. On coronary angiography, single-vessel lesions were more common in the Wellens group (11.6% vs. 5.3%, P=0.016), and almost all (97.1%) of these patients received drug-eluting stents. Notably, the Wellens group had a higher proportion of early PCI than the non-Wellens group (71% vs. 61.2%, P=0.044). At 24 months, there was no statistically significant difference in cardiac death (P=0.111) between the two groups, but the MACCEs were comparable (Wellens: 5.1% vs. non-Wellens: 13.3%, P=0.009). Age ≥65 years was the largest independent risk factor for adverse prognosis.

Conclusions

With early recognition and aggressive intervention, Wellens' syndrome is no longer a risk factor for adverse prognosis in patients with NSTEMI in the current PCI era.

Intermittent Chest Pain in a 46-Year-Old Patient

A patient in his 40s presented to the emergency department with chest pain and diaphoresis, which had also occurred 2 days earlier. He had a 20 pack-year history of smoking but no family history of cardiovascular disease. The patient’s electrocardiogram showed biphasic T waves in leads V2 and V3. What would you do next?

Critical Stenosis in Left Anterior Descending Artery: Beware of T- Wave Inversions

Wellens’ syndrome (WS) is a pattern on an electrocardiogram (ECG) characterized by biphasic T waves or deeply inverted T waves in leads V2-V3 with a recent clinical history of angina. Wellens’ pattern on the ECG is particular for critical left anterior descending artery (LAD) stenosis. Wellens’ sign and WS have been used interchangeably in the literature. However, the typical patterns of ECG changes noted are mostly represented by Wellens’ sign. These ECG changes have been crucial in identifying this subset of patients with severe LAD disease.

Wellens syndrome as an independent predictor of in-hospital cardiovascular complications

INTRODUCTION

Wellens Syndrome was described for the first time in the eighties, as an equivalent pattern of a critical lesion of the anterior descending artery. Different risk factors have been associated with a worse prognosis during hospitalisation in patients with non-ST segment elevation acute coronary syndrome. However, it is unknown whether the presence of Wellens Syndrome alone contributes to an increase in in-hospital cardiovascular complications.

MATERIAL AND METHOD

Analytical prospective cohort study in 141 patients with the diagnosis of acute coronary syndrome without ST segment elevation who underwent coronary angiography between 2016 and 2020.

RESULTS

Wellens syndrome was diagnosed in 64 patients with a mean age of 66.31 ± 12.54, of which 21 patients had a cardiac event during hospitalisation: hemodynamic complication 14 (21.9%), refractory or recurrent angina 4 (6.3%) and Acute myocardial infarction 3 (4.7%) confirming a relative risk (RR): 4.88 (95% confidence interval (CI) 1.92-12.45) p = 0.001.

CONCLUSIONS

The presence of Wellens Syndrome is independently associated with the appearance of cardiac complications during hospitalisation.Key pointsSW is now known to be a relatively frequent presentation of ACS, not addressed in depth in clinical practice guidelines for NSTEACS. This syndrome is generally caused by a severe ADA occlusion that, if not adequately treated, could evolve into a large infarction. According to the results of the different series published, the incidence of cardiovascular risk factors in SW is similar to other forms of presentation of ischaemic heart disease.At present, the exact relationship between the main cardiovascular risk factors and SW is unknown; in addition to the possible associations of this syndrome with in-hospital cardiovascular complications and its value as a predictor of the occurrence of cardiac complications, elements that are included in the results of the present study.

Wellens Sign: Monography and Single Center Experience

Objective:Wellens syndrome has been described as a clinical and electrocardiographic complex that identifies a subset of patients with unstable angina (UA) at an impending risk of myocardial infarction (MI) and death in studies published almost four decades ago, before the wide use of cardiac biomarkers such as troponins. The clinical implications of Wellens sign in a contemporary cohort of patients with non-ST elevation acute coronary syndromes (NSTEACS) is yet to be defined. Material and methods:We performed a prospective analysis of patients with acute coronary syndrome (ACS) and Wellens sign who underwent coronary angiography between January 2018 and December 2019. Patients follow-up visits were at one month and at six months. Clinical, electrocardiographic, biological and echocardiographic data were recorded at both follow-up visits. Results: A total of 79 patients were included in the statistical analysis, of whom 16 (20.25%) had pure Wellens syndrome (normal myocardial necrosis biomarkers). The prevalence of type A Wellens sign was higher than previously reported (45.6%). The culprit coronary artery was most frequently LAD (49 pts, 62.03%), followed by LM (10 patients, 12.66%), right coronary artery (RCA) (eight pts, 10.13%), instent restenosis (three pts, 3.8%), left circumflex artery (LCX) (two pts, 2.53%) and bypass graft (one pt, 1.27%). Ischaemic reccurence rate within six months was 18,99%. The rate of reccurent percutaneous revascularization procedures was 11.54% and the rate of repeat target vessel revascularization (TVR) was 5.77% at six months. All-cause mortality rate at six months was 7.59%, with 5.06% cardiovascular deaths. Conclusion: Early recognition of subtle ECG changes resembling Wellens sign in patients with chest pain is crucial as it reflects a large area of myocardium at risk. In our study, the culprit coronary artery was most frequently LAD (62.03%), with 36.7% proximal LAD culprit lesion, followed by LM (12.66%). Wellens syndrome should be considered a high risk condition that makes the conventional methods for risk assesment using risk scores unnecessary, useless and potentially deleterious. In our study, according to GRACE 1.0 risk score, 70.89% of patients were in the low risk group (1-108 points, estimated in-hospital death risk < 1%). No patient died during the initial hospitalization. All-cause mortality rate at six months was 7.59%, with 5.06% cardiovascular deaths.

[Atypical presentation of the Wellens electrocardiographic pattern associated with coronary bifurcation lesión]

We present a patient who was admitted to the emergency room due to unstable angina, with an initial electrocardiogram without signs of acute ischemia and a favorable clinical evolution. During hospitalization, she developed the Wellens electrocardiographic pattern, noted in the literature as an infrequent, poorly identified finding and with an ominous prognosis. This electrocardiographic pattern is described in precordial derivatives, suggesting a significant lesion of a principal epicardial artery; our patient had similar electrocardiographic alterations in the high lateral leads, in whom the coronary bifurcation lesion not previously described in this scenario was confirmed.

Myocardial bridging-an unusual cause of Wellens syndrome: A case report

RATIONALE

Coronary chest pain is usually ischemic in etiology and has various electrocardiographic presentations. Lately, it has been recognized that myocardial bridging (MB) with severe externally mechanical compression of an epicardial coronary artery during systole may result in myocardial ischemia. Such a phenomenon can be associated with chronic angina pectoris, acute coronary syndromes (ACS), coronary spasm, ventricular septal rupture, arrhythmias, exercise-induced atrioventricular conduction blocks, transient ventricular dysfunction, and sudden death.

PATIENT CONCERNS

We report the case of a 58-year-old woman presenting with recurrent episodes of constrictive chest pain during exercise within the last 2 weeks. Except for obesity, general and cardiovascular clinical examination on admission were normal.

DIAGNOSES

The resting 12 lead electrocardiogram (ECG) revealed changes typically for Wellens syndrome. High-sensitive cardiac troponin I was normal. We established the diagnosis of low-risk non-ST-segment elevation acute coronary syndrome with a Global Registry of Acute Coronary Events risk score of 92 points.

INTERVENTIONS

The patient underwent coronary angiography, who showed subocclusive dynamic obstruction of the left anterior descending artery due to MB.

OUTCOMES

The patient was managed conservatively. Her hospital course was uneventful and she was discharged on pharmacological therapy (clopidogrel, bisoprolol, amlodipine, atorvastatin, and metformin) with well-controlled symptoms on followup.

LESSONS

MB is an unusual cause of myocardial ischemia. Wellens syndrome is an unusual presentation of ACS. We present herein a rare case of Wellens syndrome caused by MB. This case highlights the importance of subtle and frequently overseen ECG findings when assessing patients with chest pain and second, the importance of considering nonatherosclerotic causes for ACS.