From the Guidelines
Wellens syndrome is a medical emergency that requires immediate cardiology consultation and urgent cardiac catheterization, as it indicates a critical stenosis in the proximal left anterior descending (LAD) coronary artery, signaling an impending anterior wall myocardial infarction. This condition is characterized by deeply inverted or biphasic T waves in leads V2-V3 on an electrocardiogram (ECG), often with minimal or no ST elevation, minimal or no cardiac enzyme elevation, and little to no chest pain at the time of ECG recording 1. The importance of recognizing Wellens syndrome lies in its potential to progress to a massive anterior wall myocardial infarction within days to weeks without intervention, making prompt medical attention crucial.
Some key points to consider in the management of Wellens syndrome include:
- Immediate cardiology consultation for urgent cardiac catheterization and likely revascularization
- Standard acute coronary syndrome care, including:
- Aspirin 325mg
- P2Y12 inhibitors like clopidogrel 300-600mg loading dose
- Anticoagulation with heparin
- High-intensity statin therapy
- Symptom management with beta-blockers and nitroglycerin
- Recognition of Wellens syndrome as a pre-infarction state where the coronary artery temporarily reopens after occlusion, causing characteristic ECG changes during pain-free periods 1.
It is essential to note that medical management alone is insufficient for patients with Wellens syndrome, and urgent intervention is necessary to prevent devastating anterior wall infarctions. The 12-lead ECG is a critical tool in detecting ACS, and ST-segment depression, new bundle-branch blocks, and T-wave inversion can indicate high-risk presentations in the emergency setting 1.
From the Research
Definition and Diagnosis of Wellens Syndrome
- Wellens syndrome is a clinical entity characterized by a specific electrocardiogram (ECG) pattern, typically biphasic T waves in leads V2 and V3, which is indicative of a high risk of myocardial infarction 2, 3, 4.
- The diagnosis of Wellens syndrome is critical, as it can lead to extensive anterior wall myocardial infarction and possibly sudden death if left untreated 4.
- The ECG pattern of Wellens syndrome can be overlooked, especially in patients with atypical chest pain or no chest pain at all, highlighting the importance of routine ECGs in patients presenting with symptoms that may be related to cardiac issues 2.
Clinical Presentation and Incidence
- Wellens syndrome can present with or without chest pain, and its incidence is estimated to be around 5.7% of all acute coronary syndrome (ACS) patients 5.
- Patients with Wellens syndrome are more likely to have non-ST-elevation myocardial infarction (NSTEMI) than ST-elevation myocardial infarction (STEMI) 5.
- The presence of preexisting coronary heart disease and previous percutaneous coronary intervention (PCI) is less common in patients with Wellens syndrome compared to those without the syndrome 5.
Treatment and Outcomes
- Early recognition and aggressive intervention, including urgent cardiac catheterization and coronary artery bypass grafting (CABG), are critical in preventing serious consequences of Wellens syndrome 2, 4.
- The use of medications such as antiplatelet agents, statins, beta-blockers, and renin-angiotensin-aldosterone system blockers may be beneficial in patients with myocardial infarction, including those with Wellens syndrome 6.
- The long-term outcomes of patients with Wellens syndrome are not definitively associated with an increased risk of major adverse cardiac and cerebrovascular events (MACCE) or cardiac death, but factors such as age, diabetes, and left main disease can increase the risk of adverse outcomes 5.