What is the management approach for a patient presenting with an ECG pattern consistent with Wellens' sign?

Management of Wellens' Syndrome

Patients presenting with Wellens' sign on ECG should undergo urgent cardiac catheterization and revascularization to prevent progression to a potentially fatal anterior wall myocardial infarction.

What is Wellens' Syndrome?

Wellens' syndrome is characterized by specific ECG patterns that indicate critical stenosis of the left anterior descending (LAD) coronary artery, typically in the proximal segment. There are two ECG patterns:

• Type A: Biphasic T waves in leads V2-V3
• Type B: Deep, symmetrically inverted T waves in leads V1-V4

These patterns represent a pre-infarction state that can rapidly progress to a massive anterior wall myocardial infarction if left untreated 1, 2.

Immediate Assessment and Management

1. Recognition of ECG pattern: Identify the characteristic Wellens' pattern on ECG, which may be present even when the patient is pain-free 3.

2. Risk assessment: Understand that Wellens' syndrome represents a high-risk condition regardless of conventional risk scores. In one study, 70.89% of patients with Wellens' syndrome were classified as low-risk by GRACE score, yet the condition represents impending myocardial infarction 4.

3. Cardiac biomarkers: Obtain cardiac troponin levels, but do not delay management if ECG shows Wellens' pattern, even if biomarkers are normal or only minimally elevated 5, 2.

4. Immediate cardiology consultation: Request urgent cardiology evaluation for patients with Wellens' pattern, as recommended by the 2022 ACC expert consensus 5.

Definitive Management

1. Urgent coronary angiography: Patients with Wellens' syndrome should undergo immediate coronary angiography regardless of biomarker results or risk scores 5, 2, 6.

2. Revascularization: Percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) should be performed based on coronary anatomy findings:

   • For single or double-vessel disease, PCI with stenting is typically performed
   • For left main or triple-vessel disease, CABG is recommended, particularly in patients with left ventricular dysfunction 5

3. Medical therapy while awaiting catheterization:

   • Aspirin 325 mg loading dose
   • P2Y12 inhibitor (e.g., clopidogrel, ticagrelor)
   • Anticoagulation with unfractionated heparin or low molecular weight heparin
   • Supplemental oxygen only if SaO2 < 90%
   • Pain control as needed 7

Important Considerations

• Do not perform stress testing: Exercise stress testing is contraindicated in Wellens' syndrome as it may precipitate complete LAD occlusion and massive anterior wall MI 2, 6.

• Do not delay for biomarker results: Wellens' syndrome can present with normal or only minimally elevated cardiac biomarkers, so management decisions should be based on ECG findings and clinical presentation 5, 7.

• Continuous ECG monitoring: Patients should be monitored for progression of ECG changes or development of arrhythmias while awaiting definitive management 7.

• Asymptomatic presentation: Wellens' pattern may be present even in asymptomatic patients, who still require urgent angiography due to the high risk of LAD stenosis 3.

Outcomes and Prognosis

Without appropriate intervention, Wellens' syndrome can rapidly progress to extensive anterior wall MI with significant morbidity and mortality 6. Studies have shown that early recognition and intervention can prevent this progression and improve outcomes 1, 2.

In a recent study, the culprit lesion was most frequently in the LAD (62.03%), with 36.7% in the proximal LAD, followed by left main coronary artery (12.66%) 4. Six-month all-cause mortality was 7.59%, with 5.06% cardiovascular deaths, highlighting the importance of prompt recognition and management 4.

Common Pitfalls to Avoid

• Relying solely on cardiac biomarkers, which may be normal or only minimally elevated
• Using conventional risk stratification tools like TIMI or GRACE scores, which may underestimate risk in Wellens' syndrome
• Performing stress testing, which can precipitate complete LAD occlusion
• Discharging patients with resolved chest pain but persistent Wellens' pattern on ECG
• Failing to recognize the pattern in asymptomatic patients