This is the discussion for ourÂ Snapshot CaseÂ involving a 45 year old female complaining of chest pain.
Here is the 12 lead for review:
As we recall, the patient had complained of â€œoff and onâ€ chest pain radiating to her left arm. Concerning to be sure! In addition, the patient was â€œpain freeâ€ at about the time of this 12 lead ECG.
Many of you astutely recognized the possiblity that this ECG showed the Wellensâ€™ pattern. We know that the Wellensâ€™ pattern typically occurs while the patient is pain free.Â Â IÂ was concerned that this was Wellensâ€™ also. I did think the R waves were larger than those Iâ€™ve seen in other Wellensâ€™ cases, but.. it sure looked like it could be Wellensâ€™. And after all, our chest pain patient was now pain free!
Here is an example of Wellensâ€™ (second type):
Here is V1-V6 from our patient:
Sure looked like it could be Wellensâ€™. The receiving doc in the ER was also concerned. Donâ€™t you just love catching Wellens!
The patient was admitted, and labs drawn. When I followed up to see how critical the LAD lesion was, I got some interesting news:Â Troponins came back negative. I do not know the discharge diagnosis, but it was not ACS.
Hmph. What happened?? Wellensâ€™ seemed so straight forward. Why wasnâ€™t this Wellensâ€™? I neeeeded to know!
So, I went to the most logical place for answers: Dr. Stephen Smith ofÂ Dr. Smithâ€™s ECG Blog.
Hereâ€™s how it went:
Me: Dr. Smith, what are your thoughts on this ECG? I was concerned it was Wellensâ€™â€¦
DS: These are non-diagnostic T waves. Maybe ischemia, maybe not. So this is the person you would rule out with serial trops, then stress.
DS: Or do a CT coronary angiogram.
DS: This would be a good case to post as an example of not-Wellensâ€™ waves.
So it is! I started with a good post about Wellensâ€™, and ended up with a good post aboutÂ not-Wellensâ€™. Hereâ€™s the thing though:Â I am still not sure why it is not Wellensâ€™, even though I know it is a good example of not Wellensâ€™.Â I figured I better learn the objective Wellensâ€™ criteria Dr. Smith is using!
ME: When differentiating these from Wellensâ€™ waves, is there an objective criteria you are using? Â Â
DS: Thatâ€™s the problem. There is no objective criterion. It is all my experience.
DS: I can say I haveÂ seen hundreds if not thousands of such ECGs which are not due to ACS. Many are. That is why I say non-diagnostic.
DS: When I see a Wellensâ€™ morphology, 80% of the time it really is ACS. Still not 100%.
Wait, What? 80%? I never heard that before! Basically, 1 out of every 5 Wellensâ€™ pattern we catch actually wonâ€™t be Wellensâ€™. Iâ€™ll admit, I found myself feeling a little lacking in the ECG Jedi Master department:
â€œThese arenâ€™t the wavesÂ youâ€™reÂ looking forâ€¦â€
This Snapshot case left me somewhat unsatisfied. The result was unexpected, and I didnâ€™t feel on solid ground about the ECG.Â Thatâ€™s how it goes sometimesÂ with some of our cases. Not the answers we thought weâ€™d get. Weâ€™ll just have to roll with it, and march on to the next case.
In closing, a few take home points:
- When I become a full fledged ECG Jedi Master, this ECG will obviously be not-Wellensâ€™.
- In the meantime, we must know that all that wiggles isnâ€™t Wellensâ€™. Even with a good story. Keep your guard up, but also know the limitations.
Thank you to Dr. Smith for again providing his wisdom and invaluable insights. As always, comments welcome!