Saturday, October 13, 2007
If I see a patient in Emergency Dept presented with history of typical angina pain but on arrival to ED, the patient said the pain has very much reduced, and on ECG there is deep T inversion in V2-V3 with no ST elevation, then I am not just seeing a relatively simple unstable angina case (even if the cardiac enzymes are 'negative'), but I may be seeing a patient who is considered a potential 'time bomb' for progression to full blown extensive anterior MI! This pre-infarction state is called Wellens' Syndrome.
It is very important for emergency physicians (EPs) to have a high index of suspicion for Wellens' Syndrome. A study has been done that shows that EPs at all levels of training commonly miss the diagnosis and significance of WS, with most EPs sending patients with Wellens' Syndrome to other than a critical care bed.
This is a potential pitfall for emergency physicians attempting to evaluate patients in chest pain centers!!!
A review of several chest pain center triage protocols reveals that a pain-free patient with so called "nonspecific" ECG changes, an atypical history, normal cardiac enzyme levels, may be given an appointment for exercise stress test (EST). Such ESTs are contraindicated in the presence of suspected left main or left main equivalent lesions.
Wellens' Syndrome is a preinfarction stage of coronary artery disease associated with significant obstruction (or critical stenosis) in the proximal left anterior descending (LAD) coronary artery.
Patients with Wellens' Syndrome are at high risk for development of an extensive MI of the anterior wall and death.
Once Wellen's Syndrome has been recognized, urgent coronary angiography (aggressive measures are needed)- and not stress tests of any sort - is required to evaluate the need for angioplasty or coronary bypass surgery.
This is because provocative testings, including stress imaging may precipitate AMI with significant sequelae.
Wellens and his colleagues first described the clinical and ECG criteria of this subgroup of patients with characteristic ST-T wave changes in the midprecordial leads (mainly T changes).
The following criteria for Wellens' Syndrome are:
1A. Either symmetric and deeply inverted T waves in leads V2 and V2 [ocassionally in V1, V4,V5,V6] *OR
1B. Biphasic T wwave in leads V2 and V3
2. Little or no STE (less than 1mm)
3. Little or no cardiac enzyme rise (less than twice upper normal limit)
4. No precordial pathologic Q wave
5. Typical angina pain BUT often this pattern occurs in the pain free state**
* This pattern is the more common type on 75% of cases
** In fact, during an attack of chest pain, the ST-segment-T-wave abnormalities usually normalize or develop in ST segment elevation.
1. Rhinehardt J, Brady WJ, Perron AD et al. Electrocardiographic manifestations of Wellens' syndrome. Am J Emerg Med 2002; 20 (7):638-43.
2. Tandy TK, Bottomy DP, Lewis JG. Wellens' syndrome. Ann Emerg Med 1999; 33 (3):347-51.
A photo quiz about Wellens' Syndrome can be viewed here
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This is a good time to talk about the other red herring that is the left main stem occlusion where amongst other ECG changes is the ST elevation in AVR (the forgotten lead)
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