Wellens' syndrome: Difference between revisions

(Added historical perspective, updated with customized graphic differentiating Type A, B)
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==Background==
==Background==
Initially described in 1982 where a subset of patients who did poorly with medical management of “impending myocardial infarction” (essentialy unstable angina) were found to have characteristic ECG changes. These patients were noted to be at increased risk for extensive anterior wall myocardial infarctions 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>
*T wave abnormality that is associated with critical LAD stenosis
*T wave abnormality that is associated with critical LAD stenosis
**Finding can be transient (persists for hours after pain has resolved and then disappears)
**Finding can be transient (persists for hours after pain has resolved and then disappears)
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*Type B: Inversion pattern - 75% - Deeply inverted and symmetric T-waves
*Type B: Inversion pattern - 75% - Deeply inverted and symmetric T-waves


[[Image:Wellens.jpg]]  
[[Image:Wellens.png]]  


''Note Wellens criteria should not be diagnosed in a patetient with LVH.&nbsp;''
''Note Wellens criteria should not be diagnosed in a patetient with LVH.&nbsp;''
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==Management==
==Management==
*Urgent cardiac catheterization
*Urgent cardiac catheterization
*Stress testing contraindicated


==See Also==
==See Also==

Revision as of 03:57, 6 December 2016

Background

Initially described in 1982 where a subset of patients who did poorly with medical management of “impending myocardial infarction” (essentialy unstable angina) were found to have characteristic ECG changes. These patients were noted to be at increased risk for extensive anterior wall myocardial infarctions due to proximal LAD stenosis.[1]

  • T wave abnormality that is associated with critical LAD stenosis
    • Finding can be transient (persists for hours after pain has resolved and then disappears)
    • Preinfarction stage of ACS and heralds extensive anterior wall MI

Clinical Features

Refer to Myocardial infarction

  • May be pain free at presentation and time of ECG
  • May have had previous recent episode of angina +/- associated symptoms
  • Initial cardiac enzymes are frequently normal or only slightly elevated[2][3]
  • Cocaine may cause pseudo-Wellens due to vasospasm without critical stenosis[4]

Differential Diagnosis

  • High voltage
  • PE
  • RBBB
  • Hypokalemia
  • CNS Injury
  • Persistent Juvenile T-wave pattern
  • Digitalis Effect
  • "Normal variant" STE with biphasic T-wave[5]
    • 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

Evaluation

  1. Biphasic T waves in leads V2-V3 OR symmetric, often deeply inverted T waves in V2-V3
  2. Prior history of chest pain (chest pain resolved)
  3. Little or no cardiac enzyme elevation
  4. No pathologic precordial Q waves
  5. Little or no ST-segment elevation
  6. No loss of precordial R waves

Two T-wave Characteristics (at times terms are reversed in the literature or labeled Type I and II):

  • Type A: Biphasic pattern - 25% - Biphasic T-waves (initial + deflection and terminal - deflection)
  • Type B: Inversion pattern - 75% - Deeply inverted and symmetric T-waves

Wellens.png

Note Wellens criteria should not be diagnosed in a patetient with LVH. 

Management

  • Urgent cardiac catheterization
  • Stress testing contraindicated

See Also

External Links

Mattu ECG Case - Wellens' Syndrome

Video

References

  1. 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.
  2. 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.
  3. Kannan L and Figueredo VM. Wellens' Syndrome. Jan 1, 2015. N Engl J Med 372;1.
  4. Dhawan SS. Pseudo-Wellens’ syndrome after crack cocaine use. Can J Cardiol. 2008; 24(5):404.
  5. Wang, et al. ST-segment elevation in conditions other than acute myocardial infarction. NEJM 2003, 349:2128-2135.