What is the management approach for a patient presenting with Wellens' sign on an electrocardiogram (ECG)?

Management of Wellens' Syndrome

Patients presenting with Wellens' sign on ECG should undergo urgent coronary angiography within 24 hours followed by appropriate revascularization, as this pattern indicates critical proximal left anterior descending (LAD) artery stenosis with high risk of extensive anterior myocardial infarction.

Understanding Wellens' Syndrome

Wellens' syndrome is characterized by specific ECG patterns that correlate with severe proximal LAD stenosis:

• Type A: Biphasic T waves in leads V2-V3
• Type B: Deep, symmetrically inverted T waves in leads V2-V4

Key clinical features:

• History of angina (though can occasionally present without chest pain) 1
• Normal or minimally elevated cardiac markers
• Pain-free during ECG recording
• Preserved R-wave progression without pathological Q waves
• Minimal or no ST-segment elevation

Risk Assessment and Management Algorithm

Step 1: Immediate Recognition and Risk Stratification

• Recognize Wellens' pattern on ECG as a high-risk finding regardless of GRACE or TIMI risk scores 2
• Consider Wellens' syndrome a high-risk condition requiring urgent intervention regardless of biomarker status 2
• Place patient on continuous cardiac monitoring 3
• Obtain serial troponin measurements (though often normal or only slightly elevated)

Step 2: Initial Medical Management

• Administer loading dose of aspirin (250-500mg) 3
• Initiate anticoagulation with unfractionated heparin or low molecular weight heparin 3
• Add P2Y12 inhibitor (ticagrelor preferred over clopidogrel) 4
• Administer beta-blockers if no contraindications 3
• Consider nitrates for recurrent symptoms 3
• Provide supplemental oxygen if patient has breathlessness, heart failure, or shock 3

Step 3: Invasive Management

• Arrange urgent coronary angiography within 24 hours 4, 3
• Preferably use radial access for coronary angiography to reduce bleeding complications 4
• Do not perform stress testing, as this may precipitate extensive anterior wall myocardial infarction 4, 5

Step 4: Revascularization Strategy

Based on angiographic findings:

• Single-vessel disease: PCI with stenting of the culprit lesion is first choice 4
• Left main or triple-vessel disease: CABG is recommended 4, 3
• Double-vessel disease: Decision for PCI or CABG should be made by the Heart Team 4

Important Clinical Considerations

1. Do not delay angiography - Even in asymptomatic patients with Wellens' pattern, urgent coronary angiography is warranted due to the high risk of proximal LAD stenosis 1, 6

2. Avoid provocative testing - Exercise stress testing is contraindicated as it may precipitate complete LAD occlusion and extensive anterior myocardial infarction 5

3. Recognize atypical presentations - Wellens' syndrome can occasionally present without chest pain 1, and the ECG patterns may persist over weeks 6

4. Consider coronary spasm - In rare cases, Wellens' pattern may be caused by coronary spasm rather than fixed stenosis 7

5. Monitor for complications - Patients with Wellens' syndrome are at high risk for progression to extensive anterior myocardial infarction if left untreated 5

Prognosis and Follow-up

• Without appropriate intervention, patients with Wellens' syndrome are at high risk for extensive anterior myocardial infarction
• With proper management and revascularization, outcomes can be significantly improved
• After revascularization, implement comprehensive secondary prevention including dual antiplatelet therapy, beta-blockers, ACE inhibitors, statins, and cardiac rehabilitation 3
• Monitor for recurrent ischemia, which occurs in approximately 19% of patients within 6 months 2