Wellens' syndrome: Difference between revisions

 
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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>
*First described in 1982
 
**Subset of patients fared poorly with medical management of “impending myocardial infarction” ([[unstable angina]])
*T wave abnormality that is associated with critical LAD stenosis
***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>
**Finding can be transient (persists for hours after pain has resolved and then disappears)
***Shared characteristic ECG changes
**Preinfarction stage of [[ACS]] and heralds extensive anterior wall MI
****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==
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*[[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]]
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==Evaluation==
==Evaluation==
#History of chest pain
*History of [[chest pain]]
#Normal or slightly-elevated cardiac enzymes
**[[ECG]] may be normal during episode of pain
#No precordial Q-waves
*Normal or slightly-elevated [[cardiac enzymes]]
#Isoelectric or <1mm ST-segment elevation
*No precordial Q-waves
#Pattern present in pain-free state
*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


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 A (25%)
*Type B (75%): Deep, symmetrically inverted T-waves in V2/V3
**Biphasic T-wave in V2/V3
*Type B (75%)
**Deep, symmetrically inverted T-waves in V2/V3


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


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


==Management==
==Management==
*Urgent cardiac catheterization
*Urgent cardiac catheterization
*Stress testing contraindicated
*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.