1. The Second Affiliated Hospital of Wenzhou Medical College Wellens syndrome 温州医学院附属第二医院 杨鹏麟

2. The Second Affiliated Hospital of Wenzhou Medical College Pain free and in VT? “Can you take a look at the patient in bed 6? I think he is having runs of VT!” Pain free and in VT?

3. The Second Affiliated Hospital of Wenzhou Medical College Pain free and in VT? You are called to the monitored area in ED to see a 62-year man who is awaiting a bed under the medics for investigation of an episode of chest pain earlier in the day. He is currently pain free, sat up in bed looking undistressed with a blood pressure of 150/90. The monitor shows intermittent runs of a broad complex rhythm. His ECG is shown below:

4. The Second Affiliated Hospital of Wenzhou Medical College ECG

5. The Second Affiliated Hospital of Wenzhou Medical College Questions Q1. What is the electrophysiological basis for the broad complex rhythm? Q2. What treatment is required for the broad complex rhythm? Q3. What is the clinical significance of the other ECG changes? Q4. How should this patient be managed?

6. The Second Affiliated Hospital of Wenzhou Medical College ECG

7. The Second Affiliated Hospital of Wenzhou Medical College Q3 What is the clinical significance of the other ECG changes? In a patient presenting with recent chest pain, an ECG showing biphasic or deeply inverted T waves in leads V2-4 is highly specific for a critical occlusion of the proximal LAD. These patients may be pain free by the time the ECG is taken and have normally or minimally elevated cardiac enzymes; however, they are at extremely high risk for extensive anterior wall MI within the next 2 weeks.

8. The Second Affiliated Hospital of Wenzhou Medical College Q4 How should this patient be managed? This patient needs urgent cardiology referral, admission to a monitored bed and early PCI (ideally within 48 hours). Medical management (including thrombolysis) is frequently ineffective in this condition. The only way to prevent progression to extensive anterior MI is revascularization via PCI or CABG.

9. The Second Affiliated Hospital of Wenzhou Medical College Result of CAG

10. The Second Affiliated Hospital of Wenzhou Medical College Wellens syndrome 1982 Am Heart J 1982;103:730-6

11. The Second Affiliated Hospital of Wenzhou Medical College  近期有胸痛发作（约 20-30 分钟）  在 V 2 -V 3 导联出现 特征性 T 波改变 （无症状时记录的 ECG ）  无明显 ST 段偏移（无症状时）  无 QRS 波形态改变  心肌标志物可正常或轻度增高  部分患者可出现左室运动障碍 Wellens 综合症诊断标准

12. The Second Affiliated Hospital of Wenzhou Medical College Wellens 综合症 T 波两种不同的表现形式 Type 1Type 2

13. The Second Affiliated Hospital of Wenzhou Medical College Wellens 综合症造影结果 LAD 近端 50-99% 不稳定病变，极易进展为急性 ST 段抬高 的广泛前壁心梗

14. The Second Affiliated Hospital of Wenzhou Medical College Wellens 综合症的意义 在于早期识别 LAD 近端的不稳定病变，此类患者极易在 2 周内进展 为急性 ST 段抬高的广泛前壁心梗（ 75% ），应尽早行 PCI 。 一旦发生急性闭塞，即使争分夺秒地行急诊 PCI 也只能挽救部分心 肌，对于那些即将发生急性闭塞的病变早期识别和及时处理，避 免一次 STEMI 是非常有意义的。这时候行 PCI 成功率高，并发症少， 对病人价值最大。

15. The Second Affiliated Hospital of Wenzhou Medical College Part VI: Acute Ischemia/Infarction In patients suspected of having ACS on clinical grounds, marked (greater than or equal to 2mm symmetrical precordial T-wave inversion strongly suggests acute ischemia, particularly that due to a critical stenosis of the left anterior descending coronary artery (LAD). Patients with this ECG finding are at high risk if given medical treatment alone. Revascularization will often reverse both the T-wave inversion and wall-motion disorder.

16. The Second Affiliated Hospital of Wenzhou Medical College Some studies have cast doubt on the prognostic value of isolated T- wave inversion.However, deep symmetrical inversion of the T-waves in the anterior chest leads is often related to a significant stenosis of the proximal left anterior descending coronary artery or main stem. Guidelines for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes European Heart Journal (2007) 28, 1598–1660 doi:10.1093/eurheartj/ehm161 2007 ESC Guidelines

17. The Second Affiliated Hospital of Wenzhou Medical College Wellens 综合症带来的思考 1 、 ACS 持续胸痛 5 小时患者的心电图 2 、持续胸痛 1 小时患者的心电图 3 、院外持续胸痛 1-2 小时，就诊时胸痛已缓解 4 、反复胸痛，每次持续 20-30 分钟，就诊时无胸痛 5 、反复胸痛，每次持续 5-10 分钟，就诊时无胸痛 在一些缺血发作时间短， QRS 波、 ST 段及 TnI 无 明显变化的患者身上如何寻找 ACS 的线索？

18. The Second Affiliated Hospital of Wenzhou Medical College Wellens 综合征的机制 持续缺血时间的长短决定 ECG 形态的演变 急性 STEMI 的演变

19. The Second Affiliated Hospital of Wenzhou Medical College 心肌缺血再灌注 血流中断 5min 时，心肌处于可逆性损伤，心肌灌注迅速恢 复后，缺血心肌已形成的各种功能的损伤可以快速、完全性 恢复。 当血流中断 15-30min 时，缺血造成的心肌功能障碍明显加 重，此时发生再灌注时，已发生的心肌细胞代谢、电生化等 功能障碍常需数小时 - 数天甚至更长时间才能完全恢复，这 种心肌功能延迟恢复的现象称为心肌顿抑。 超过 30min 时以上时，则可造成心肌细胞不可逆的缺血、坏 死。

20. The Second Affiliated Hospital of Wenzhou Medical College Wellens 综合症带来的启示 在一些缺血发作时间短（ 20-30 分钟）， QRS 波、 ST 段及 TnI 无明显变化的患者身上如何寻 找 ACS 的线索？ 通常这些患者在胸痛发作后数小时 - 数天 ECG 存在 T 波的演变。

21. The Second Affiliated Hospital of Wenzhou Medical College 入院无胸痛时胸痛时 Case 1

22. The Second Affiliated Hospital of Wenzhou Medical College Lead V2 V3 V4 胸痛时无胸痛时 The Wellens’ syndrome EKG pattern is usually paradoxically present during a pain-free state, and can seem to normalize somewhat during ischemic pain.

23. The Second Affiliated Hospital of Wenzhou Medical College V1 V5 拇指法则 Rule of thumb V1 无胸痛胸痛 拇指法则 =

24. The Second Affiliated Hospital of Wenzhou Medical College CAG 结果 我的策略 -“ 亚急诊 PCI”

25. The Second Affiliated Hospital of Wenzhou Medical College Case 2 无胸痛时 ECG

26. The Second Affiliated Hospital of Wenzhou Medical College CAG 及 PCI 结果

27. The Second Affiliated Hospital of Wenzhou Medical College 术后第二天 ECG

28. The Second Affiliated Hospital of Wenzhou Medical College 术后第 10 天 ECG

29. The Second Affiliated Hospital of Wenzhou Medical College

30. 未进展为 Q 波的 STEMI Case 3 胸痛 1h 余, 已缓解， Wellens T ? A B C D

31. The Second Affiliated Hospital of Wenzhou Medical College Wellens T wave ? Inverted T waves on electrocardiogram: myocardial ischemia versus pulmonary embolism Sanjay Sarin Journal of Electrocardiology 38 (2005) 361– 363

32. The Second Affiliated Hospital of Wenzhou Medical College Wellens T wave ? Global T-wave inversion in a 77-year-old woman Proc (Bayl Univ Med Cent) 2009;22(1):81–82

33. The Second Affiliated Hospital of Wenzhou Medical College Negative T wave

34. The Second Affiliated Hospital of Wenzhou Medical College 心尖肥厚性心肌病

35. The Second Affiliated Hospital of Wenzhou Medical College 3 种常见 T 波倒置的特点 V2 V3 V4 缺血性 T 波 脑血管意外 心尖肥厚性 心肌病 7 th Braunwald's Heart Disease 134

36. The Second Affiliated Hospital of Wenzhou Medical College T wave Inversion Electrocardiographic T-wave changes underlying acute cardiac and cerebral events John N. Catanzaro American Journal of Emergency Medicine (2008) 26, 716–720 S1Q3T3Deep and splayed Variant in Pregnancy Pulmonary Embolus Prolonged QT intervalNormal QT interval Cerebrovascular Accident Subarachnoid Hemmorhage Digoxin Effect Nonconvulsive status Epilepticus Pulmonary Embolus Myocardial stunning Myocardial infarction Subendocardial infarction Wellens Syndrome Left Ventricular Strain Athletic heart syndrome Normal Variant “Adolescent”

37. The Second Affiliated Hospital of Wenzhou Medical College A case of sudden death due to ???

38. The Second Affiliated Hospital of Wenzhou Medical College Title in here This is Wellen’s warning

39. The Second Affiliated Hospital of Wenzhou Medical College

41. 08 ESC STEMI Guideline

42. The Second Affiliated Hospital of Wenzhou Medical College 2010 ESC Guidelines on myocardial revascularization