Wellens' syndrome: Difference between revisions
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== | ==Background== | ||
*First described in 1982, a set of EKG changes specific for critical, proximal stenosis of LAD | |||
**At risk for extensive anterior wall myocardial infarction due to proximal LAD stenosis<ref>de Zwaan C, Bär FW, Wellens HJ. Characteristic electrocardiographic pattern indicating a critical stenosis high in left anterior descending coronary artery in patients admitted because of impending myocardial infarction. Am Heart J. 1982;103(4 Pt 2):730-736.</ref> | |||
***In the original study, a subset of patients fared poorly with medical management of “impending myocardial infarction” | |||
***75% of patients with these findings will later develop anterior MI (if not treated with PCI) | |||
**Characteristic EKG changes: T wave abnormality (2 types, shown below) associated with the stenosis<ref>Rhinehardt J, Brady WJ, Perron AD, Mattu A. Electrocardiographic manifestations of Wellens' syndrome. American Journal of Emergency Medicine. 2002;20(7):638-643. doi:10.1053/ajem.2002.34800.</ref> | |||
*Commonly described as a STEMI equivalent, but per the 2022 ACC Expert Consensus Decision Pathway, it's instead categorized as an ischemic change<ref>2022 ACC Expert Consensus Decision Pathway on the Evaluation and Disposition of Acute Chest Pain in the Emergency Department: A Report of the American College of Cardiology Solution Set Oversight Committee, Journal of the American College of Cardiology, Volume 80, Issue 20,2022,Pages 1925-1960,ISSN 0735-1097.</ref> | |||
**This is because patient is not currently having an MI; rather, it's a post-ischemic change | |||
== | ==Clinical Features== | ||
*Symptoms of [[Myocardial infarction]] or ischemia | |||
*Symptoms have often resolved at presentation | |||
*May have previous recent episodes of [[angina]] or anginal equivalents | |||
*Initial cardiac enzymes are frequently normal or slightly elevated<ref>Ünlüer EE et al. Red Flags in Electrocardiogram for Emergency Physicians: Remembering Wellens' Syndrome and Upright T wave in V1. West J Emerg Med. 2012 May; 13(2): 160–162.</ref><ref>Kannan L and Figueredo VM. Wellens' Syndrome. Jan 1, 2015. N Engl J Med 372;1.</ref> | |||
*[[Cocaine]] use may cause pseudo-Wellens due to vasospasm without critical stenosis<ref>Dhawan SS. Pseudo-Wellens’ syndrome after crack cocaine use. Can J Cardiol. 2008; 24(5):404.</ref> | |||
== | ==Differential Diagnosis== | ||
*High voltage | |||
*[[PE]] | |||
*[[ECG (Basics)|RBBB]] | |||
*[[Hypokalemia]] | |||
*[[head injury|CNS Injury]] | |||
*Persistent Juvenile T-wave pattern | |||
*[[Digitalis Effect]] | |||
*"Normal variant" STE with biphasic T-wave<ref>Wang, et al. ST-segment elevation in conditions other than acute myocardial infarction. NEJM 2003, 349:2128-2135.</ref> | |||
**Common in young, healthy, Black males | |||
**Patterns that are NOT found in Wellen's | |||
***High voltage complexes | |||
***Notching at J-point ("fishhook") | |||
***Concave upward ST segment followed by steep drop in T wave | |||
{{ST elevation DDX}} | |||
== | ==Evaluation== | ||
*History of [[chest pain]] | |||
**[[ECG]] may be normal during episode of pain | |||
*Normal or slightly-elevated [[cardiac enzymes]] | |||
*No precordial Q-waves | |||
*Isoelectric or <1mm [[ST elevation|ST-segment elevation]] | |||
*Wellens' sign present in pain-free state | |||
**Wellens' sign during pain-free state plus recent history of angina and normal to slightly elevated [[cardiac enzymes]] = Wellen's syndrome | |||
**Findings can be transient (persists for hours after pain has resolved and then disappears) | |||
[[Category: | ===Two T-wave Characteristics (at times terms are reversed in the literature or labeled Type I and II):=== | ||
*Type A (25%) | |||
**Biphasic T-wave in V2/V3 | |||
*Type B (75%) | |||
**Deep, symmetrically inverted T-waves in V2/V3 | |||
[[Image:Wellens.png]] | |||
*IF there is acute occlusion MI, Wellens T wave patterns may normalize and convert to ST elevations | |||
*Note Wellens criteria should not be applied to patients with [[LVH]] | |||
==Management== | |||
*Treat similarly to MI, including antiplatelets and anticoagulation<ref>Miner B, Grigg WS, Hart EH. Wellens Syndrome. [Updated 2023 Jul 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.</ref> | |||
*Urgent cardiac catheterization is the definitive treatment | |||
*Stress testing contraindicated | |||
**Can precipitate an acute myocardial infarction and sudden death | |||
==Disposition== | |||
*Admit | |||
==See Also== | |||
*[[STEMI equivalents]] | |||
==External Links== | |||
[https://litfl.com/wellens-syndrome-ecg-library/ LIFTL - Wellens Syndrome] | |||
==References== | |||
<references/> | |||
[[Category:Cardiology]] | |||
Latest revision as of 15:48, 16 September 2025
Background
- First described in 1982, a set of EKG changes specific for critical, proximal stenosis of LAD
- At risk for extensive anterior wall myocardial infarction due to proximal LAD stenosis[1]
- In the original study, a subset of patients fared poorly with medical management of “impending myocardial infarction”
- 75% of patients with these findings will later develop anterior MI (if not treated with PCI)
- Characteristic EKG changes: T wave abnormality (2 types, shown below) associated with the stenosis[2]
- At risk for extensive anterior wall myocardial infarction due to proximal LAD stenosis[1]
- Commonly described as a STEMI equivalent, but per the 2022 ACC Expert Consensus Decision Pathway, it's instead categorized as an ischemic change[3]
- This is because patient is not currently having an MI; rather, it's a post-ischemic change
Clinical Features
- Symptoms of Myocardial infarction or ischemia
- Symptoms have often resolved at presentation
- May have previous recent episodes of angina or anginal equivalents
- Initial cardiac enzymes are frequently normal or slightly elevated[4][5]
- Cocaine use may cause pseudo-Wellens due to vasospasm without critical stenosis[6]
Differential Diagnosis
- High voltage
- PE
- RBBB
- Hypokalemia
- CNS Injury
- Persistent Juvenile T-wave pattern
- Digitalis Effect
- "Normal variant" STE with biphasic T-wave[7]
- Common in young, healthy, Black males
- Patterns that are NOT found in Wellen's
- High voltage complexes
- Notching at J-point ("fishhook")
- Concave upward ST segment followed by steep drop in T wave
ST Elevation
- Cardiac
- ST-segment elevation myocardial infarction (STEMI)
- Post-MI (ventricular aneurysm pattern)
- Previous MI with recurrent ischemia in same area
- Wellens' syndrome
- Coronary artery vasospasm (eg, Prinzmetal's angina)
- Coronary artery dissection
- Pericarditis
- Myocarditis
- Aortic dissection in to coronary
- Left ventricular aneurysm
- Left ventricular pseudoaneurysm
- Early repolarization
- Left bundle branch block
- Left ventricular hypertrophy (LVH)
- Myocardial tumor
- Myocardial trauma
- RV pacing (appears as Left bundle branch block)
- Brugada syndrome
- Takotsubo cardiomyopathy
- AVR ST elevation
- Other thoracic
- Metabolic
- Drugs of abuse (eg, cocaine, crack, meth)
- Hyperkalemia (only leads V1 and V2)
- Hypothermia ("Osborn J waves")
- Medications
Evaluation
- History of chest pain
- ECG may be normal during episode of pain
- Normal or slightly-elevated cardiac enzymes
- No precordial Q-waves
- Isoelectric or <1mm ST-segment elevation
- Wellens' sign present in pain-free state
- Wellens' sign during pain-free state plus recent history of angina and normal to slightly elevated cardiac enzymes = Wellen's syndrome
- Findings can be transient (persists for hours after pain has resolved and then disappears)
Two T-wave Characteristics (at times terms are reversed in the literature or labeled Type I and II):
- Type A (25%)
- Biphasic T-wave in V2/V3
- Type B (75%)
- Deep, symmetrically inverted T-waves in V2/V3
- IF there is acute occlusion MI, Wellens T wave patterns may normalize and convert to ST elevations
- Note Wellens criteria should not be applied to patients with LVH
Management
- Treat similarly to MI, including antiplatelets and anticoagulation[8]
- Urgent cardiac catheterization is the definitive treatment
- Stress testing contraindicated
- Can precipitate an acute myocardial infarction and sudden death
Disposition
- Admit
See Also
External Links
References
- ↑ de Zwaan C, Bär FW, Wellens HJ. Characteristic electrocardiographic pattern indicating a critical stenosis high in left anterior descending coronary artery in patients admitted because of impending myocardial infarction. Am Heart J. 1982;103(4 Pt 2):730-736.
- ↑ Rhinehardt J, Brady WJ, Perron AD, Mattu A. Electrocardiographic manifestations of Wellens' syndrome. American Journal of Emergency Medicine. 2002;20(7):638-643. doi:10.1053/ajem.2002.34800.
- ↑ 2022 ACC Expert Consensus Decision Pathway on the Evaluation and Disposition of Acute Chest Pain in the Emergency Department: A Report of the American College of Cardiology Solution Set Oversight Committee, Journal of the American College of Cardiology, Volume 80, Issue 20,2022,Pages 1925-1960,ISSN 0735-1097.
- ↑ Ünlüer EE et al. Red Flags in Electrocardiogram for Emergency Physicians: Remembering Wellens' Syndrome and Upright T wave in V1. West J Emerg Med. 2012 May; 13(2): 160–162.
- ↑ Kannan L and Figueredo VM. Wellens' Syndrome. Jan 1, 2015. N Engl J Med 372;1.
- ↑ Dhawan SS. Pseudo-Wellens’ syndrome after crack cocaine use. Can J Cardiol. 2008; 24(5):404.
- ↑ Wang, et al. ST-segment elevation in conditions other than acute myocardial infarction. NEJM 2003, 349:2128-2135.
- ↑ Miner B, Grigg WS, Hart EH. Wellens Syndrome. [Updated 2023 Jul 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.