What is Wellens' syndrome (Left Anterior Descending coronary artery disease)?

From the Guidelines

Wellen's syndrome is a critical cardiac condition characterized by specific ECG patterns that indicate a high risk of imminent anterior wall myocardial infarction due to a critical stenosis in the proximal left anterior descending (LAD) coronary artery. The classic ECG findings include deeply inverted or biphasic T-waves in leads V2-V3, often with preserved R waves and minimal ST-segment elevation. According to the 2024 ESC guidelines for the management of chronic coronary syndromes 1, patients with significant single- or double-vessel disease involving the proximal LAD and insufficient response to guideline-directed medical therapy should undergo CABG or PCI to improve symptoms and outcomes.

Key Points

• The ECG patterns in Wellen's syndrome are a medical emergency, requiring immediate attention and intervention.
• Patients presenting with Wellen's syndrome should be treated as having unstable angina and transferred urgently to a cardiac catheterization laboratory for coronary angiography and likely percutaneous coronary intervention (PCI) 1.
• While awaiting transfer, standard acute coronary syndrome therapy should be initiated, including aspirin, clopidogrel, and anticoagulation with heparin or enoxaparin.
• Beta-blockers and nitrates may help manage symptoms, but the primary goal is to restore blood flow to the affected area of the heart.

Treatment Approach

• CABG or PCI is recommended over medical therapy alone to improve symptoms and outcomes in patients with significant single- or double-vessel disease involving the proximal LAD 1.
• The choice between CABG and PCI depends on various factors, including the patient's overall health, the complexity of the coronary anatomy, and the presence of other medical conditions.
• In general, CABG is recommended for patients with complex coronary anatomy or those who are at high risk for complications with PCI 1.

From the Research

Definition and Characteristics

• Wellens' syndrome is characterized by an electrocardiographic pattern of T-wave changes associated with a critical stenosis of the left anterior descending artery (LAD) 2.
• It is a pre-infarction syndrome with non-classical ischemic ECG changes and unremarkable cardiac biomarkers, also known as LAD coronary T-wave syndrome or the 'widow maker' 3.
• The syndrome is associated with a high risk of extensive anterior myocardial infarction, left ventricular dysfunction, arrhythmias, and death if not recognized promptly 2, 3.

Electrocardiographic Findings

• The characteristic ECG findings associated with Wellens' syndrome consist of deep, symmetric T-wave inversions in the anterior precordial leads 4.
• It can also present as biphasic T-wave inversions in the same ECG leads 2, 4.
• Type A Wellens' sign has been reported to have a higher prevalence than previously reported, at 45.6% 5.

Clinical Implications and Management

• Early recognition of subtle ECG changes resembling Wellens' sign in patients with chest pain is crucial as it reflects a large area of myocardium at risk 5.
• The culprit coronary artery is most frequently the LAD, with 36.7% proximal LAD culprit lesion, followed by LM 5.
• Wellens' syndrome should be considered a high-risk condition that makes conventional methods for risk assessment using risk scores unnecessary, useless, and potentially deleterious 5.
• Delay in urgent angiography and intervention can result in anterior myocardial infarction, left ventricular dysfunction, arrhythmias, and death 3.
• Successful management of Wellens' syndrome has been reported with cardiac catheterization, angioplasty, and stenting 6.