Wellens' syndrome

Background

• 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 CAD, and heralds extensive anterior wall MI

Criteria

1. Biphasic T waves in leads V2-V3 OR symmetric, often deeply inverted T waves in V2-V3
2. Prior history of chest pain (CP 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:

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

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

Differential Diagnosis

• High voltage
• PE
• RBBB
• Hypokalemia
• CNS Injury
• Persistent Juvenile T-wave pattern
• Digitalis Effect

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
  • Pneumomediastinum
  • Pneumothorax
  • Pulmonary embolism
• Metabolic
  • Drugs of abuse (eg, cocaine, crack, meth)
    • Cocaine chest pain
  • Hyperkalemia (only leads V1 and V2)
  • Hypothermia ("Osborn J waves")
• Medications
  • Tricyclic (TCA) toxicity
  • Digoxin

Treatment

1. Urgent cardiac catheterization

Stress testing contraindicated, may prove fatal

Source

Wellens’ Syndrome. Annals of Emergency Medicine, March, 1999