What is the management of a patient with Wellens syndrome (characterized by deep inverted T waves in the anterior leads on electrocardiogram (ECG)) presenting with chest pain?

Management of Wellens Syndrome

Wellens syndrome requires urgent coronary angiography with percutaneous coronary intervention (PCI) within 24 hours, and stress testing or exercise is absolutely contraindicated as it can precipitate extensive anterior wall myocardial infarction. 1, 2

Immediate Recognition and Diagnosis

Wellens syndrome is a pre-infarction state indicating critical stenosis of the proximal left anterior descending (LAD) coronary artery that demands urgent recognition. 2, 3, 4

Diagnostic Criteria:

• History of recent chest pain (often resolved at time of presentation) 2, 4
• Characteristic ECG findings in precordial leads V1-V4: 1, 2, 3
  • Type A (75% of cases): Biphasic T waves (positive-negative) in V2-V3 2, 4
  • Type B (25% of cases): Deep, symmetric T-wave inversions in V1-V4 2, 3, 4
• Normal or minimally elevated cardiac biomarkers (troponin may be negative or only slightly elevated) 2, 4, 5
• No pathologic Q waves and preserved R-wave progression 4
• No significant ST-segment elevation 2, 4

Critical Pitfall: The deep symmetrical T-wave inversion across precordial leads indicates critical stenosis of the LAD and should never be mistaken for a benign finding or attributed to other causes without excluding Wellens syndrome first. 1, 3

Immediate Management (First 10 Minutes)

Initial Assessment:

• Obtain 12-lead ECG within 10 minutes of first medical contact 1, 6, 7
• Establish continuous cardiac monitoring with defibrillator patches placed 1, 6
• Assess vital signs including blood pressure, heart rate, and oxygen saturation 1
• Draw blood immediately for high-sensitivity troponin, complete blood count, electrolytes, and coagulation studies 1, 6

Anti-Ischemic Therapy:

• Administer sublingual nitroglycerin 0.3-0.4 mg every 5 minutes for up to 3 doses if systolic BP >90 mmHg and no contraindications 1, 6
• Transition to IV nitroglycerin if chest pain persists 1, 6
• Administer supplemental oxygen only if oxygen saturation <90% 1, 6
• Morphine IV may be given for refractory chest pain, though it is second-line 1, 6

Immediate Antithrombotic Therapy:

• Aspirin 160-325 mg loading dose immediately (then 75-100 mg daily) 1, 6
• Ticagrelor 180 mg loading dose (preferred over clopidogrel for more potent platelet inhibition) 1, 6
• Parenteral anticoagulation: Fondaparinux 2.5 mg subcutaneously or unfractionated heparin/LMWH with dose adjusted for renal function 1, 6

Urgent Invasive Strategy - DO NOT DELAY

Wellens syndrome mandates urgent coronary angiography within 24 hours, and ideally as soon as possible, as this represents a very high-risk acute coronary syndrome. 1, 2, 4

Timing of Angiography:

• Immediate (<2 hours) if any of the following are present: 1, 6
  • Hemodynamic instability or cardiogenic shock
  • Recurrent or ongoing chest pain refractory to medical treatment
  • Life-threatening arrhythmias
  • Acute heart failure
• Early (<24 hours) for all other Wellens syndrome patients, as the ECG pattern itself indicates critical LAD stenosis requiring intervention 1, 2, 4

Radial access is mandatory for coronary angiography to reduce bleeding complications. 1, 6

Critical Contraindications in Wellens Syndrome

ABSOLUTE CONTRAINDICATIONS - DO NOT PERFORM:

• Exercise stress testing or any provocative testing is absolutely contraindicated as it can precipitate extensive anterior wall MI 2, 4
• Conservative management with risk stratification using TIMI score alone is inappropriate - these patients require urgent angiography regardless of TIMI score 2
• Discharge from emergency department is contraindicated even if chest pain has resolved and troponin is negative 2, 4, 5

Expected Angiographic Findings and Intervention

Coronary angiography typically reveals critical stenosis (>70%) of the proximal LAD coronary artery requiring PCI with drug-eluting stent placement. 2, 3, 4, 5 In some cases, thrombus may be present requiring catheter-directed thrombectomy prior to stenting. 5

Post-Intervention Medical Therapy

Following successful PCI, initiate: 8

• Dual antiplatelet therapy: Aspirin plus ticagrelor for 12 months 1, 6
• High-intensity statin therapy immediately 6
• Beta-blocker within first 24 hours if no contraindications 6, 8
• ACE inhibitor or ARB if LVEF ≤40%, heart failure, hypertension, or diabetes 6, 8

Why This Matters - Morbidity and Mortality Impact

Failure to recognize Wellens syndrome and proceed urgently to angiography results in extensive anterior wall myocardial infarction in 75% of patients within days to weeks, with significant morbidity and mortality. 2, 4 Early recognition and urgent PCI prevents this devastating outcome and preserves left ventricular function and quality of life. 2, 3, 5