Wellens Syndrome Treatment
Patients with Wellens syndrome require urgent cardiac catheterization with percutaneous coronary intervention (PCI) to prevent extensive anterior myocardial infarction and death. 1, 2, 3
Immediate Recognition and Risk
Wellens syndrome represents a critical pre-infarction state characterized by:
- Deeply inverted or biphasic T-waves in anterior precordial leads (V2-V4) 1, 4, 5
- Critical proximal left anterior descending (LAD) artery stenosis 1, 3
- Normal or minimally elevated cardiac biomarkers 3, 4
- Symptoms occurring during a pain-free interval after recent chest pain 2, 4
The key danger is that 75% of patients will develop extensive anterior wall myocardial infarction within weeks if not urgently revascularized. 1, 3
Treatment Algorithm
Step 1: Immediate Stabilization
- Admit to monitored cardiac unit 2
- Administer aspirin, heparin, and nitrates for symptom control 2
- Avoid stress testing or exercise tolerance testing—this can precipitate acute myocardial infarction 3
Step 2: Urgent Cardiac Catheterization
- Perform coronary angiography within 24-48 hours, ideally emergently 1, 2, 3
- The typical finding is critical (>70%) proximal LAD stenosis 1, 3
- Proceed directly to PCI with stent placement during the same procedure 4
Step 3: Revascularization Options
- Percutaneous coronary intervention with drug-eluting stent is the preferred approach 4
- Catheter-directed thrombectomy may be needed if thrombus is present 4
- Coronary artery bypass grafting is reserved for cases unsuitable for PCI 3
Critical Pitfalls to Avoid
Do not discharge patients with characteristic ECG findings even if cardiac biomarkers are negative—this is a defining feature of Wellens syndrome, not reassurance. 3, 4
Do not perform stress testing—physical exertion can trigger the complete occlusion you are trying to prevent. 3
Do not delay catheterization for conservative medical management—one case report documented a patient who died 10 days after discharge when catheterization was deferred. 2
Special Considerations
Atypical Presentations
- Patients may present with epigastric pain, syncope, or burning chest pain rather than classic angina 1, 4
- The ECG pattern is only visible during pain-free intervals; during active ischemia, ST-segment changes may be non-specific 2
COVID-19 Context
- While some guidelines suggest conservative management for stable acute coronary syndrome patients with COVID-19, Wellens syndrome is an exception requiring urgent catheterization regardless of infection status 2
- Delaying intervention in this setting has resulted in fatal outcomes 2
Anatomic Variations
- Occasionally, the culprit lesion may be in the proximal circumflex artery rather than LAD, though ECG changes remain in anterior leads 1
- Always perform complete coronary angiography to identify all significant lesions 1
Post-Intervention Management
Following successful revascularization: