Should a Wellens EKG (Electrocardiogram) be treated as a STEMI (ST-Elevation Myocardial Infarction)?

Management of Wellens Syndrome: Not a STEMI but Requires Urgent Intervention

Wellens syndrome should not be activated as a STEMI, but rather requires emergent cardiology consultation and urgent cardiac catheterization due to its high risk for progression to extensive anterior wall myocardial infarction.

Understanding Wellens Syndrome

Wellens syndrome is characterized by specific ECG patterns that indicate critical proximal left anterior descending (LAD) artery stenosis:

• Type A: Biphasic T waves in leads V2-V3
• Type B: Deep, symmetric T-wave inversions in leads V2-V4

These patterns typically appear during pain-free periods in patients with a recent history of anginal chest pain.

ECG Classification According to Guidelines

According to the 2022 ACC Expert Consensus Decision Pathway, Wellens syndrome is categorized separately from STEMI 1:

• STEMI: Requires management per ACCF/AHA STEMI guidelines
• ST-segment elevation in aVR with multilead ST-depression: Managed per NSTE-ACS guidelines
• Wellens Sign: Classified under "Other findings concerning for acute ischemia or infarction" requiring:
  • Emergent cardiology consultation
  • Serial ECGs over short intervals

The 2017 ESC guidelines similarly do not classify Wellens syndrome as a STEMI equivalent that would automatically trigger the STEMI pathway 1.

Clinical Significance and Management

Wellens syndrome represents a critical pre-infarction state with important clinical implications:

• High Risk Pattern: Indicates proximal LAD stenosis that can rapidly progress to extensive anterior wall MI 2
• Poor Response to Medical Therapy: Unlike other forms of unstable angina, Wellens syndrome typically does not respond well to medical management alone
• Need for Urgent Intervention: Requires cardiac catheterization with PCI, but not necessarily with the same door-to-balloon time targets as STEMI 3

Management Algorithm

1. Recognition: Identify characteristic ECG patterns during pain-free intervals

   • Type A: Biphasic T waves in V2-V3
   • Type B: Deep, symmetric T-wave inversions in V2-V4

2. Initial Assessment:

   • Obtain cardiac biomarkers (troponin)
   • Perform serial ECGs to monitor for progression
   • Rule out pseudo-Wellens syndrome (can occur with LVH) 4

3. Consultation and Intervention:

   • Obtain emergent cardiology consultation 1
   • Arrange for urgent (not emergent) cardiac catheterization
   • Do not discharge the patient or perform stress testing, which could precipitate complete LAD occlusion

4. Medical Management while awaiting catheterization:

   • Dual antiplatelet therapy
   • Anticoagulation
   • High-intensity statin
   • Monitor for progression to STEMI

Common Pitfalls and Caveats

• Misdiagnosis: Wellens syndrome can be mistaken for non-cardiac conditions due to its presentation during pain-free periods
• Stress Testing: Exercise stress testing is contraindicated as it may precipitate complete LAD occlusion and extensive anterior MI
• Pseudo-Wellens: Left ventricular hypertrophy can mimic Wellens pattern 4
• Delayed Recognition: The biphasic T-wave pattern (Type A) may be subtle and easily missed, leading to delayed intervention and worse outcomes 2

Conclusion

While Wellens syndrome is not a STEMI and should not trigger the STEMI pathway, it represents a high-risk condition requiring urgent cardiac catheterization. The 2022 ACC Expert Consensus Decision Pathway clearly categorizes it as requiring emergent cardiology consultation rather than immediate STEMI activation 1.