From the Guidelines
Wellens' syndrome is a critical cardiac condition characterized by specific ECG changes that indicate impending myocardial infarction due to critical stenosis of the left anterior descending (LAD) coronary artery, and patients presenting with this syndrome require immediate cardiology consultation and preparation for cardiac catheterization. The diagnostic ECG findings include deeply inverted or biphasic T waves in leads V2-V3, often with minimal or no ST elevation, minimal or no cardiac enzyme elevation, and a history of recent anginal chest pain that has resolved at the time of ECG recording, as described in the 2021 ACC/AHA/SCAI guideline for coronary artery revascularization 1. According to the practical implementation of the guidelines for unstable angina/non-ST-segment elevation myocardial infarction in the emergency department, deep symmetrical T-wave inversion across the precordial leads may indicate a critical stenosis of the left anterior descending coronary artery (Wellen’s phenomenon) 1.
Key Characteristics of Wellens' Syndrome
- Deeply inverted or biphasic T waves in leads V2-V3
- Minimal or no ST elevation
- Minimal or no cardiac enzyme elevation
- History of recent anginal chest pain that has resolved at the time of ECG recording
Management of Wellens' Syndrome
- Immediate hospitalization
- Antiplatelet therapy (aspirin 325mg loading dose followed by 81mg daily, plus a P2Y12 inhibitor like clopidogrel 600mg loading then 75mg daily)
- Anticoagulation with heparin
- Preparation for coronary angiography with likely percutaneous coronary intervention, as recommended by the 2021 ACC/AHA/SCAI guideline for coronary artery revascularization 1
Importance of Recognition
Recognition of Wellens' syndrome is crucial as it allows for intervention before irreversible myocardial damage occurs, and patients with this syndrome should not undergo stress testing as it may precipitate a complete occlusion of the already critically stenosed LAD. The pathophysiology involves reperfusion of severely ischemic myocardium, causing the characteristic T wave changes during pain-free periods, representing a "window of opportunity" before complete vessel occlusion occurs.
From the Research
Definition and Characteristics
- Wellens' syndrome is an electrocardiography (EKG) pattern that indicates critical proximal left anterior descending artery (LAD) stenosis 2.
- It is characterized by deeply inverted T-waves or biphasic T-waves in the anterior precordial chest leads in a patient with unstable angina 2, 3.
- The syndrome is a pre-infarction stage due to the critical stenosis of the proximal left anterior descending artery, and it is associated with a high risk of extensive anterior myocardial infarction and death if left untreated 2, 4, 5, 3, 6.
Clinical Presentation
- Patients with Wellens' syndrome typically present with symptoms consistent with acute coronary syndrome, such as chest pain 2, 4, 5, 3, 6.
- The syndrome can also present with atypical symptoms, such as epigastric pain and syncope 2, burning chest and epigastric pain 5, or even no symptoms at all.
- The cardiac biomarker is often within the normal limit or only slightly elevated in this condition 5.
Diagnosis and Treatment
- The diagnosis of Wellens' syndrome is based on the characteristic EKG changes, which include biphasic T-waves in V2-V3 (type A) or negative deep T-waves in V2-V4 (type B) 3.
- Urgent cardiac catheterization with percutaneous coronary intervention is the definitive treatment for Wellens' syndrome 2, 4, 5, 3, 6.
- Delaying treatment can lead to devastating outcomes, such as myocardial infarction or even death 4, 3.