Wellens' syndrome: Difference between revisions

 
(11 intermediate revisions by 5 users not shown)
Line 1: Line 1:
==Background==
==Background==
*T wave abnormality that is associated with critical LAD stenosis
*First described in 1982
**Finding can be transient (persists for hours after pain has resolved and then disappears)
**Subset of patients fared poorly with medical management of “impending myocardial infarction” ([[unstable angina]])
**Preinfarction stage of [[ACS]] and heralds extensive anterior wall MI
***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>
***Shared characteristic ECG changes
****T wave abnormality associated with critical LAD 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>
**Findings can be transient (persists for hours after pain has resolved and then disappears)


==Clinical Features==
==Clinical Features==
Refer to [[Myocardial infarction]]
*Symptoms of [[Myocardial infarction]] or ischemia
*May be pain free at presentation and time of ECG
*Symptoms have often resolved at presentation
*May have had previous recent episode of angina +/- associated symptoms
*May have previous recent episodes of [[angina]] or anginal equivalents
*Initial cardiac enzymes are frequently normal or only 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>
*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]] 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>
*[[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==
==Differential Diagnosis==
Line 16: Line 19:
*[[ECG (Basics)|RBBB]]
*[[ECG (Basics)|RBBB]]
*[[Hypokalemia]]
*[[Hypokalemia]]
*CNS Injury
*[[head injury|CNS Injury]]
*Persistent Juvenile T-wave pattern
*Persistent Juvenile T-wave pattern
*[[Digitalis Effect]]
*[[Digitalis Effect]]
Line 28: Line 31:


==Evaluation==
==Evaluation==
#Biphasic T waves in leads V2-V3 OR symmetric, often deeply inverted T waves in V2-V3
*History of [[chest pain]]
#Prior history of chest pain (chest pain resolved)
**[[ECG]] may be normal during episode of pain
#Little or no cardiac enzyme elevation
*Normal or slightly-elevated [[cardiac enzymes]]
#No pathologic precordial Q waves  
*No precordial Q-waves
#Little or no ST-segment elevation  
*Isoelectric or <1mm [[ST elevation|ST-segment elevation]]
#No loss of precordial R waves
*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


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


*Type A: Biphasic pattern - 25% - Biphasic T-waves (initial + deflection and terminal - deflection)
[[Image:Wellens.png]]
*Type B: Inversion pattern - 75% - Deeply inverted and symmetric T-waves


[[Image:Wellens.jpg]]
''Note Wellens criteria should not be applied to  patients with [[LVH]]''
 
''Note Wellens criteria should not be diagnosed in a patetient with LVH.&nbsp;''


==Management==
==Management==
*Urgent cardiac catheterization
*Urgent cardiac catheterization
*Stress testing contraindicated
==Disposition==
*Admit


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

Latest revision as of 03:06, 5 February 2021

Background

  • First described in 1982
    • Subset of patients fared poorly with medical management of “impending myocardial infarction” (unstable angina)
      • At risk for extensive anterior wall myocardial infarction due to proximal LAD stenosis[1]
      • Shared characteristic ECG changes
        • T wave abnormality associated with critical LAD stenosis[2]
    • Findings can be transient (persists for hours after pain has resolved and then disappears)

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[3][4]
  • Cocaine use may cause pseudo-Wellens due to vasospasm without critical stenosis[5]

Differential Diagnosis

  • High voltage
  • PE
  • RBBB
  • Hypokalemia
  • CNS Injury
  • Persistent Juvenile T-wave pattern
  • Digitalis Effect
  • "Normal variant" STE with biphasic T-wave[6]
    • 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

  • 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

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

Wellens.png

Note Wellens criteria should not be applied to patients with LVH

Management

  • Urgent cardiac catheterization
  • Stress testing contraindicated

Disposition

  • Admit

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