What is the management of a patient with an ECG (electrocardiogram) showing a Wellens sign?

Management of Wellens Syndrome

Patients with Wellens syndrome should undergo urgent cardiac catheterization with percutaneous coronary intervention due to the high risk of developing extensive anterior wall myocardial infarction from critical left anterior descending artery stenosis. 1, 2

Definition and Recognition

• Wellens syndrome is characterized by specific ECG patterns that indicate critical proximal left anterior descending (LAD) coronary artery stenosis 1, 3
• Two ECG patterns are recognized:
  • Type A: Biphasic T waves in leads V2-V3 1
  • Type B: Deep negative T waves in leads V2-V4 1, 2
• These ECG changes typically occur during pain-free periods in patients with a history of intermittent chest pain, though some cases may present without chest pain 4

Clinical Significance

• Wellens syndrome has a high positive predictive value for critical LAD stenosis 5
• Without prompt intervention, patients are at high risk for developing extensive anterior wall myocardial infarction 3, 2
• Recognition of this pattern is crucial as it allows for intervention before the development of myocardial infarction 5

Diagnostic Approach

• A 12-lead ECG should be acquired and interpreted as soon as possible at the time of first medical contact to facilitate early diagnosis and triage 6
• Serial ECGs should be performed if the initial ECG is equivocal or does not show evidence to support the clinical suspicion of myocardial ischemia 6
• Cardiac biomarkers may be normal or only slightly elevated in Wellens syndrome 4

Management Algorithm

1. Immediate Risk Stratification:

   • Recognize ECG pattern of Wellens syndrome even in asymptomatic patients 4
   • Consider as high-risk NSTE-ACS requiring urgent evaluation 6

2. Initial Management:

   • Initiate ECG monitoring as soon as possible to detect life-threatening arrhythmias 6
   • Administer aspirin (162-325 mg) if no contraindications 6
   • Consider nitroglycerin for symptom relief if present 6

3. Definitive Management:

   • Urgent cardiac catheterization with percutaneous coronary intervention is the definitive treatment 1, 2
   • Primary PCI strategy should be implemented within 120 minutes of first medical contact 6
   • For patients presenting within 12 hours of symptom onset, reperfusion therapy is indicated 6
   • If PCI cannot be performed within 120 minutes and there are no contraindications, consider fibrinolytic therapy 6

4. Post-Intervention Care:

   • Standard post-ACS management including dual antiplatelet therapy 6
   • Serial ECGs to monitor for changes 7
   • Echocardiography to assess left ventricular function 7

Important Considerations and Pitfalls

• Failure to recognize Wellens syndrome can lead to devastating outcomes including myocardial infarction or death 1
• Even asymptomatic patients with Wellens ECG pattern should undergo coronary angiography due to the risk of severe LAD stenosis 4
• The ECG changes may be present during pain-free periods, making it easy to miss if clinicians only focus on patients with active chest pain 3, 2
• Radial access for cardiac catheterization is preferred over femoral access to reduce the risk of access site bleeding and vascular complications 6

Special Situations

• Patients presenting late (12-48 hours after symptom onset) should still be considered for a routine primary PCI strategy 6
• In asymptomatic patients, routine PCI of an occluded infarct-related artery more than 48 hours after symptom onset is not indicated 6
• For patients with non-diagnostic initial ECG but strong clinical suspicion, extending the standard 12-lead ECG with additional leads (V7-V9) may help identify those with posterior wall involvement 6