What is the description and management of Wellens syndrome?

Wellens Syndrome: Description and Management

Wellens syndrome is a critical pattern of ECG changes indicating proximal left anterior descending (LAD) artery stenosis that requires urgent cardiac catheterization to prevent impending myocardial infarction and death. 1, 2

Diagnostic Criteria

Wellens syndrome is characterized by:

• History of anginal chest pain that resolves before ECG is taken
• ECG changes during pain-free period:
  • Type A: Biphasic T waves in leads V2-V3 (less common, ~45% of cases)
  • Type B: Deep, symmetrically inverted T waves in leads V2-V4 (more common)
• Normal or minimally elevated cardiac biomarkers
• No pathological Q waves
• Minimal or no ST-segment elevation
• Normal precordial R-wave progression
• Preserved or minimal loss of precordial R-wave progression

Clinical Significance

Wellens syndrome represents a medical emergency because:

• It indicates critical proximal LAD stenosis (62-80% of cases) 3, 2
• Without intervention, it typically progresses to extensive anterior myocardial infarction 4
• The mortality rate can be significant (6-month cardiovascular mortality ~5%) 3

Management Algorithm

1. Immediate Recognition

   • Identify characteristic ECG pattern during pain-free period
   • Consider Wellens syndrome as high-risk regardless of normal biomarkers

2. Initial Stabilization

   • Place on continuous cardiac monitoring
   • Establish IV access
   • Administer aspirin 325mg chewed (if not contraindicated)
   • Consider antiplatelet therapy (P2Y12 inhibitor)
   • Administer high-intensity statin

3. Urgent Evaluation

   • Obtain emergent cardiology consultation 5
   • Perform serial ECGs over short intervals to monitor for progression 5
   • Avoid provocative testing (e.g., stress tests) which may precipitate complete occlusion

4. Definitive Management

   • Urgent coronary angiography with intent for percutaneous coronary intervention
   • Medical management alone is insufficient and potentially dangerous
   • Time is critical - delay increases risk of complete LAD occlusion

Common Pitfalls to Avoid

1. Misinterpreting as non-urgent: Wellens syndrome may be overlooked because patients are often pain-free when the ECG is obtained.

2. Relying on cardiac biomarkers: Normal troponins do not exclude Wellens syndrome; it represents impending infarction, not completed infarction.

3. Ordering stress testing: Exercise stress testing is contraindicated as it may precipitate complete LAD occlusion and extensive anterior MI.

4. Discharging patients: Even if pain resolves and biomarkers are negative, these patients require urgent intervention.

5. Confusing with other T-wave abnormalities: Differentiate from other causes of T-wave inversion such as pulmonary embolism, cerebrovascular events, or cardiomyopathies.

Prognosis

Without appropriate intervention, Wellens syndrome has a poor prognosis:

• High risk of progression to extensive anterior wall MI
• Six-month all-cause mortality rate of approximately 7.6% 3
• Six-month cardiovascular mortality rate of approximately 5% 3

With timely recognition and appropriate coronary intervention, outcomes can be significantly improved and myocardial damage prevented.