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 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
• Cocaine may cause pseudo-Wellens due to vasospasm without critical stenosis

Differential Diagnosis

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

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

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

Management

• Urgent cardiac catheterization

See Also

• STEMI equivalents

External Links

Mattu ECG Case - Wellens' Syndrome

Video

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