What is the diagnosis and recommended acute management for a patient who had recent anginal chest pain that resolved and now shows deep symmetric T‑wave inversions or biphasic T‑waves in leads V2‑V3 on electrocardiogram (ECG) consistent with Wellens syndrome?

Wellens Syndrome: Diagnosis and Acute Management

Immediate Recognition and Action

A patient with recent resolved chest pain showing deep symmetric T-wave inversions (≥2 mm) or biphasic T-waves in leads V2-V3 has Wellens syndrome—a critical pre-infarction state requiring urgent coronary angiography within 24 hours to prevent massive anterior wall myocardial infarction. 1, 2

This ECG pattern indicates 70-99% stenosis of the proximal or mid-left anterior descending (LAD) coronary artery, and without revascularization, approximately 75% of patients progress to extensive anterior wall MI within weeks. 2

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Diagnostic Criteria

Wellens syndrome requires all of the following features:

• Deep symmetric T-wave inversions ≥2 mm (Type B, most common ~75%) or biphasic T-waves (Type A, ~25%) in leads V2-V3, often extending to V4-V6 3, 1, 2
• Recent chest pain that has resolved (pain-free at presentation or within hours-days) 2, 4
• Normal or minimally elevated cardiac biomarkers (troponin often normal or only slightly elevated) 2, 4
• Preserved R-wave progression without pathologic Q-waves 2
• QT prolongation frequently present 1

The pain-free presentation occurs because collateral circulation temporarily maintains perfusion despite critical stenosis. 1

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First 10-Minute Management Protocol

Execute these steps immediately upon ECG recognition:

• Activate the ACS pathway immediately—treat this as equivalent urgency to STEMI even without ST-elevation 1, 2
• Administer aspirin 162-325 mg orally (loading dose) 1, 2
• Establish large-bore IV access and continuous cardiac monitoring 1, 2
• Initiate dual antiplatelet therapy: aspirin plus P2Y12 inhibitor (ticagrelor or prasugrel) 2, 4
• Start anticoagulation with low-molecular-weight heparin or unfractionated heparin 2, 4
• Obtain serial high-sensitivity troponin at presentation, 1-2 hours, and 3 hours 2
• Give sublingual nitroglycerin if any residual chest discomfort persists 2

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Critical Management Principles

What TO Do:

• Schedule urgent coronary angiography within 24 hours (many experts recommend completion within 24 hours given the imminent risk) 1, 2, 4
• Proceed directly to catheterization—this pattern requires intervention regardless of TIMI risk score or biomarker levels 1, 4
• Plan for revascularization with PCI and drug-eluting stent placement (or CABG for multivessel disease) 1, 2
• Administer high-intensity statin therapy 2, 4

What NOT To Do (Critical Contraindications):

• Never perform stress testing—this is contraindicated and dangerous in Wellens syndrome 1, 4
• Never use fibrinolytic therapy—this is a non-STEMI presentation where thrombolytics are contraindicated 3, 1, 2
• Never pursue conservative medical management alone—this carries a 75% risk of progression to extensive anterior MI 2, 4

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Anatomical and Prognostic Context

The typical lesion is a critical stenosis (70-99%) in the proximal or mid-LAD artery with preserved collateral flow, explaining why biomarkers remain normal initially. 2, 5, 6 Coronary angiography typically reveals plaque rupture with thrombosis and minimal lumen area. 6

Without revascularization, three-quarters of patients develop extensive anterior wall MI leading to marked left ventricular dysfunction, cardiogenic shock, or death. 2, 7 Successful revascularization reverses both the T-wave inversions and wall motion abnormalities. 3, 1

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Differential Diagnosis to Exclude

Before finalizing the diagnosis, exclude these mimics:

• Intracranial hemorrhage (produces similar deep T-wave inversions with QT prolongation; perform neurological assessment if clinically indicated) 3, 2, 4
• Takotsubo cardiomyopathy (shows apical ballooning on echo but normal coronaries on angiography) 3, 1
• Pulmonary embolism (may show right-sided T-wave changes) 1
• Left ventricular hypertrophy (different T-wave morphology and clinical context) 2

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Post-Revascularization Management

After successful PCI or CABG:

• Continue dual antiplatelet therapy for at least 12 months after stent placement 2
• Maintain high-intensity statin therapy indefinitely 2
• Add beta-blocker if left ventricular systolic dysfunction persists 1, 2
• Initiate ACE inhibitor or ARB for cardioprotection 1, 2
• Enroll in cardiac rehabilitation with aggressive risk factor modification 2

Successful revascularization typically results in complete resolution of symptoms and ECG changes. 1, 4

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Common Pitfalls to Avoid

• Do not be reassured by normal troponin levels—Wellens syndrome often presents with normal or minimally elevated biomarkers 2, 4
• Do not be reassured by absence of chest pain—the ECG pattern persists after pain resolution and indicates ongoing critical stenosis 4, 6
• Do not delay catheterization for "further risk stratification"—this pattern itself defines the patient as highest risk 1, 2
• Do not mistake T-wave pseudonormalization for improvement—this can represent worsening ischemia 6