What is the management of a suspected Wellens sign?

From the Guidelines

The management of a suspected Wellens sign requires immediate cardiology consultation and preparation for cardiac catheterization, as it indicates critical stenosis of the left anterior descending (LAD) coronary artery that may progress to an anterior wall myocardial infarction. According to the European Society of Cardiology guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation 1, patients with suspected acute coronary syndrome (ACS) should be evaluated in a hospital and seen immediately by a qualified physician. The initial evaluation should include a symptom-orientated physical examination, assessment of the likelihood of coronary artery disease (CAD), and an electrocardiogram (ECG) to detect ST-segment deviation or other abnormalities.

Key components of the initial treatment include:

• Aspirin, with an initial dose of 150–300 mg non-enteric formulation followed by 75–100 mg/day 1
• A P2Y12 inhibitor, such as ticagrelor or clopidogrel, with a loading dose 1
• Anticoagulation, with options including fondaparinux, enoxaparin, or unfractionated heparin (UFH) 1
• Oral β-blocker, if the patient is tachycardic or hypertensive without signs of heart failure 1

It is crucial to note that stress testing is contraindicated in patients with suspected Wellens syndrome, as it may precipitate complete occlusion of the LAD and massive anterior wall infarction. The definitive treatment is coronary angiography with revascularization, typically via percutaneous coronary intervention with stent placement. This aggressive approach is justified because Wellens syndrome has a high correlation with significant LAD stenosis and high risk of progression to extensive anterior myocardial infarction if not promptly addressed.

From the Research

Management of Suspected Wellens Sign

The management of a suspected Wellens sign involves prompt recognition and intervention to prevent extensive anterior wall myocardial infarction. Key aspects of management include:

• Emergency cardiac catheterization is recommended for patients with Wellens' syndrome, regardless of COVID-19 infection status 2
• Urgent percutaneous intervention is crucial in patients with Wellens syndrome, as failure to identify this clinical syndrome could result in significant morbidity and mortality 3
• Conventional management of patients with NSTEMI and unstable angina using risk stratification with TIMI score may not be appropriate in patients with Wellens syndrome 3
• Early recognition of subtle ECG changes resembling Wellens sign in patients with chest pain is crucial, as it reflects a large area of myocardium at risk 4

Importance of Early Intervention

Early intervention is critical in patients with Wellens syndrome, as it can prevent extensive anterior wall myocardial infarction. Studies have shown that:

• Patients with Wellens syndrome are at high risk of myocardial infarction and death, and early recognition and intervention can significantly improve outcomes 5, 4
• The culprit coronary artery is most frequently the left anterior descending (LAD) artery, followed by the left main (LM) artery 4
• Ischemic recurrence rate within six months is high, highlighting the need for close follow-up and monitoring 4

Special Considerations

In some cases, the management of Wellens syndrome may require special consideration, such as:

• Patients with suspected COVID-19 infection, where conservative management may be recommended for hemodynamically stable patients 2
• Patients with atypical presentations, such as isolated throat pain, where a high index of suspicion is required to diagnose Wellens syndrome 5
• Patients with coronary artery spasm, where conservative medical therapy may be effective 6