Can Severe Cachexia Mimic Wellens' Sign on ECG?
No, severe cachexia itself does not directly mimic Wellens' sign on ECG, but the underlying cardiac conditions that cause cachexia (particularly heart failure with left ventricular hypertrophy) can produce T-wave abnormalities that resemble Wellens' pattern—this is termed "pseudo-Wellens syndrome."
Understanding the Distinction
What is Wellens' Syndrome
- Wellens' syndrome represents critical proximal left anterior descending (LAD) artery stenosis characterized by specific T-wave changes (biphasic or deeply inverted T-waves in precordial leads V2-V6), history of anginal chest pain, normal or minimally elevated cardiac markers, preserved R-wave progression, and absence of significant Q waves 1
- The natural history without intervention is progression to anterior wall myocardial infarction 1
Cachexia and Cardiac Manifestations
- Cardiac cachexia occurs in 10-15% of patients with chronic heart failure and involves generalized loss across all body compartments including lean tissue, fat tissue, and bone tissue 2
- Cachectic heart failure patients commonly have left ventricular hypertrophy (LVH) and neurohormonal abnormalities including elevated norepinephrine, epinephrine, cortisol, renin, and aldosterone 3
The Pseudo-Wellens Phenomenon
LVH as the Mimicker
- Left ventricular hypertrophy secondary to hypertension or heart failure can produce anterior T-wave abnormalities that mimic Wellens' syndrome—this is called pseudo-Wellens syndrome 4
- In a documented case, a patient with newly diagnosed hypertension and LVH presented with biphasic EKG changes in leads V2-V6 concerning for Wellens' syndrome, but cardiac catheterization revealed normal coronary anatomy 4
Clinical Implications for Cachectic Patients
- Patients with severe cachexia from heart failure are likely to have underlying LVH, which is the actual cause of Wellens-like T-wave changes rather than the cachexia itself 4, 3
- The cachexia is a marker of advanced disease severity and poor prognosis, but the ECG changes stem from the structural cardiac abnormalities (LVH) rather than the wasting syndrome 5, 3
Diagnostic Approach
When Evaluating Anterior T-Wave Abnormalities
- Consider LVH as a potential cause of pseudo-Wellens syndrome, particularly in patients with hypertension or heart failure 4
- In patients without acute coronary syndrome presentation and when T-wave abnormalities are not classic for Wellens-type changes, non-invasive imaging (echocardiography, cardiac MRI, or stress testing) may be indicated initially instead of proceeding directly to cardiac catheterization 4
- Look for echocardiographic evidence of LVH, which would support pseudo-Wellens syndrome rather than true LAD stenosis 4
Key Distinguishing Features
- True Wellens' syndrome requires a history of recent anginal chest pain, whereas pseudo-Wellens from LVH may occur without typical anginal symptoms 1
- The T-wave changes in true Wellens' syndrome are persistent but eventually normalize after definitive management of the LAD stenosis 1
- Pseudo-Wellens from LVH will persist as long as the structural abnormality remains 4
Critical Pitfall to Avoid
Do not assume all anterior T-wave abnormalities in cachectic patients represent acute coronary syndrome requiring immediate catheterization. Consider the underlying cardiac structural abnormalities (particularly LVH from heart failure or hypertension) that commonly accompany cachexia as alternative explanations for Wellens-like ECG patterns 4, 3. A targeted echocardiogram can rapidly identify LVH and guide appropriate management decisions 4.