Wellens syndrome

A70-year-old woman presented with a 24-hour history of intermittent left arm pain. She had hypertension and a family history of premature coronary artery disease. Electrocardiography (ECG; Figure 1A) showed deep symmetric T-wave inversions in leads V1 to V4 and elevated troponin I level (0.82 μg/L). She was treated according to contemporary guidelines for non-ST segment elevation myocardial infarction. The risk of death or recurrent ischemic event was 19.9% (TIMI [Thrombolysis in Myocardial Infarction]1 score of 4). Urgent coronary angiography showed 90% stenosis of the proximal left anterior descending coronary artery (Figure 1B), which was successfully revascularized with a single drug-eluting stent. The history and initial ECG and angiographic findings were in keeping with Wellens syndrome. Transthoracic echocardiography 24 hours later showed a normal left ventricle ejection fraction. Dual antiplatelet therapy for one year was prescribed, along with cardiac rehabilitation.

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Figure 1:

(A) Electrocardiogram showing the Wellens pattern (black arrows) in the precordial leads of a 70-year-old woman who presented to the emergency department with intermittent pain in the left arm over the preceding 24 hours. (B) Coronary angiogram showing 90% stenosis of the proximal left anterior descending artery (white arrow).

In the first report of Wellens syndrome, de Zwaan and colleagues2 described a subgroup of patients with unstable angina who were at high risk of extensive acute myocardial infarction of the anterior wall. These patients had distinctive ECG findings, including deep symmetric T-wave inversion or biphasic T waves in the anterior precordial leads, ST-segment changes (elevation or depression), absence of Q waves and normal R-wave progression. The characteristic T-wave changes have 69% sensitivity, 89% specificity and 86% positive predictive value for clinically significant disease of the left anterior descending artery evident on coronary angiography.3 Although the pathophysiology is unknown, edema from the ischemic myocardial cell injury may result in the characteristic T-wave changes.4 These ECG findings are commonly seen in patients who have had recent ischemic chest pain but who may be pain-free at the time of presentation. Recognition of this ominous pattern is crucial for early diagnosis and intervention.5