Yes, you absolutely need to worry about Wellens' syndrome—this ECG pattern demands urgent evaluation and intervention.
Your ECG findings of deep T-wave inversions (4mm in V2, 3mm in V3) extending through V1-V5 are highly concerning for Wellens' syndrome Type B, which indicates critical proximal or mid-LAD stenosis and imminent risk of massive anterior wall myocardial infarction. 1, 2
Why This Pattern Is Dangerous
Deep symmetrical T-wave inversions in V2-V4 strongly suggest critical stenosis of the proximal left anterior descending coronary artery, even in the absence of chest pain ("anterior Wellens sign"). 1
Wellens' syndrome represents a pre-infarction state that progresses to massive and potentially fatal anterior wall MI in the majority of untreated cases. 2, 3
The extension of T-wave inversions through V5 makes this pattern even more concerning, as it suggests a larger territory at risk. 1
T-wave inversion ≥2mm in two or more adjacent leads is rarely observed in healthy individuals and mandates comprehensive cardiac evaluation. 1, 4
Immediate Actions Required
Urgent Risk Stratification
Obtain serial troponin measurements at 0,1-2, and 3 hours to assess for acute myocardial injury, even if initial values are normal. 5, 4
Perform serial 12-lead ECGs to assess for dynamic changes or evolution to ST-segment elevation. 1, 5
Admit for continuous cardiac monitoring, as Wellens' syndrome carries high risk for progression to acute MI. 4
Definitive Diagnostic Testing
Urgent coronary angiography is indicated to identify the culprit LAD lesion, as this pattern typically reflects >70-95% stenosis requiring revascularization. 2, 6, 7
While awaiting angiography, initiate dual antiplatelet therapy, anticoagulation, beta-blockers, and statins per acute coronary syndrome protocols. 4, 8
Do not perform stress testing in suspected Wellens' syndrome, as exercise can precipitate complete LAD occlusion and massive anterior MI. 7
Critical Distinguishing Features of Wellens' Syndrome
Type A vs Type B Pattern
Type B (75% of cases): Deep, symmetrical T-wave inversions in V2-V3 (or extending further as in your case)—this is what you're describing. 2, 6
Classic Clinical Context
Wellens' syndrome typically presents with recent chest pain that has resolved at the time the characteristic ECG is obtained. 2, 8, 3
The ECG pattern appears during pain-free periods, which can falsely reassure clinicians. 7, 3
Cardiac biomarkers may be normal or only minimally elevated, which does not exclude the diagnosis. 7, 3
No ST-segment elevation is present, distinguishing it from STEMI. 8, 3
Alternative Diagnoses to Consider (But Don't Delay Evaluation)
While Wellens' syndrome is the primary concern, other serious conditions can present with similar T-wave patterns:
Hypertrophic cardiomyopathy: Particularly with lateral lead involvement, though your pattern is more anterior. 1, 4
Arrhythmogenic right ventricular cardiomyopathy: When T-wave inversions extend beyond V1, though typically more right-sided. 1, 5
Myocarditis: Can present with T-wave inversions and troponin elevation without chest pain. 5
Pulmonary embolism: Differential diagnosis for T-wave inversions with elevated troponin. 5
Common Pitfalls to Avoid
Do not dismiss this pattern as a normal variant or "non-specific changes"—T-wave inversions of this depth (≥2mm) in multiple anterior leads are pathological until proven otherwise. 1, 4
Do not wait for troponin elevation before pursuing definitive evaluation—Wellens' syndrome can occur with normal or minimally elevated biomarkers. 7, 3
Do not assume the patient is stable just because they are currently pain-free—this is the classic presentation of Wellens' syndrome before catastrophic MI. 2, 3
Do not order stress testing as the initial diagnostic approach—this can precipitate complete LAD occlusion. 7
Expected Angiographic Findings
Critical stenosis (typically 70-95%) of the proximal or mid-LAD is the classic finding. 2, 6, 7
Some cases show plaque rupture with thrombosis on intravascular ultrasound. 3
Fractional flow reserve may occasionally be falsely reassuring in the acute setting, so anatomic severity should guide decision-making. 7
Treatment and Prognosis
Percutaneous coronary intervention with stent placement is the definitive treatment and typically results in excellent outcomes when performed before MI develops. 8, 6, 3
Medical therapy alone is insufficient for most cases of Wellens' syndrome with critical stenosis. 2, 6
Early recognition and revascularization prevent massive anterior MI and significantly improve prognosis. 3