1. Wellens’ Syndrome Geoff Lampard PGY-1 Jan 6 th 2011 ECG Rounds

2. Case 1  55yo male with history of stable angina  Presents to ED with ischemic chest pain

3. …. pain resolves with NTG…..  Serum TnT returns normal  What do you see in the ECG?

4. Case 2  57 yo male with 4/10 pressure-like chest pain  ASA, O 2, 2 x SL NTG sprays with EMS  Pain now improving

5. … and pain free…….

6. Case 3  54M with pressure like RSCP, diaphoresis  NTG and morphine relieves pain. ECG follows:

7. Now 1 minute into the stress test……  Anterior wall STEMI.  Immediately taken for cath and found an extensive proximal LAD lesion

8. The widowmaker

9. Wellens’ Syndrome First recognised in early 1980’s in a subgroup of UA patients with precordial T- wave changes in the pain free period who developed large anterior MI’s. All patients who met their criteria had ≥ 50% LAD stenosis 26/145 patients admitted for UA developed characteristic ECG findings at or within 24hrs of admission

10. Key concept #1 Wellens is relatively common (14-18% of UA patients)

11. ½ way through study, medical management was aborted and all were given preferential angiography 75% of medically managed patients developed anterior MI’s within 3 weeks

12. Key concept #2 Wellens is a preinfarction stage of CAD Mean time to infarction: 8.5 days

13. 1.ECG findings: a.Symmetric, deeply inverted T waves in V2-3. Occasionally in V1,V4-6, or b.Biphasic T waves in V2-3 plus c.Isoelectric or minimally elevated (<1mm) ST 2.No precordial Q-waves 3.History of angina 4.Pattern in pain free state 5.Normal or slightly elevated serum markers Criteria

14. Key concept #3 It is best seen during the pain- free period…. Get serial or pain-free ECG’s from UA patients!

15. Deep Inverted (figures A-C) ~75% of Wellens Biphasic pattern (D-F) ~25% of cases

16. But remember, the differential for t-wave inversion is large. Acute ischemia LVH BBB Late pericarditis PE CNS pathology Myocarditis Digitalis Old MI etc. etc. etc.

17. Key concept #4 Patients need early angiography. Get cardiology involved in the ED!

19. Case 1, pain free

20. Case 2, pain free

21. Case 3, pain free….

22. Wellens’ is not uncommon. Remember the 2 characteristic ECG changes Get a pain-free ECG! Wellens’ is a sign of impending MI. Requires urgent assessment.

23. Recommended further reading

24. Questions? De Zwann C, Bar FW, Wellens JHH: Characteristic electrocardiographic pattern indicating a critical stenosis high in left anterior descending coronary artery in patients admitted because of impending myocardial infarction. Am Heart J 1982. 103:730-736 De Zwann C, Bar FW, Janssen JH, et al: Angiographic and clinical characteristics of patents with unstable angina showing an ECG pattern indicating critical narrowing of the proximal LAD coronary artery. Am Heart J 1989. 117:657-665 Rhinehardt J, Brady WJ, Perron AD, Mattu A. Electrocardiographic Manifestations of Wellens’ Syndrome. Am Journal Emerg Med 2002. 20:638-643. Lilaonitkul M, Ronbinson K, Roberts M. Wellens’ Syndrome: significance of ECG pattern recognition in the emergency department. Emerg Med J. 2009. 26:750-751