Skip to content

Archives for wellens-syndrome

See all posts in the network tagged with wellens-syndrome

Name that ECG: 66 year old female – Findings

1 comment

This is the conclusion to our Name that ECG case: 66 year old female, resolved chest pain.

66 year old female, resolved chest pain.

Name that ECG: 66 year old female

 

Rhythm:

  • Rate: atrial rate of ~55 bpm, ventricular rate of ~55 bpm
  • Regularity: regular
  • P-waves: sinus (upright in I and II), associated 1:1 with the QRS
  • PRi: 140 ms
  • QRS duration: 90 ms

Bonus points:

  • Axis: -45 degrees, left axis deviation, LAFB
  • Bundle Branches: normal conduction
  • QTc: normal (<1/2 R-R interval), 420 ms (Bazett's Formula)
  • ST/T-waves:
    • T-waves: flipped T-waves in aVL, biphasic V2-V5 consistent with Wellen's Syndrome
    • ST-elevation: none noted
    • ST-depression: none noted

Differentials:

  • Normal sinus rhythm in a patient with Wellen's Syndrome
    • Possible high-grade stenosis of the LAD with recent reperfusion

Notes:

  • Wellen's Syndrome should be regarded with the same importance as a STEMI during assessment and transport.
Posted by on December 24, 2012 • Filed under: ems-topics • Tagged: , , ,

62 year old male: Chest Discomfort – Conclusion

1 comment

This is the conclusion to our three part case series, 62 year old male: Chest Discomfort. Before reading the conclusion, we suggest you check out Part I and Part II. Thanks again to Vince DiGiulio, EMT-CC for this wonderful case!

When we last left off, our patient had experienced a resolution of his chest pain accompanied by changes on his 12-Lead ECG. The ED physician had called cardiology, but they were unimpressed. Are we comfortable with this?

Let's review our patients'  first 12-Lead.

Well Page Him Again - Initial 12-Lead

We have a narrow complex, regular rhythm at 90 bpm consistent with a normal sinus rhythm. Flat or downsloping ST segments are visible in leads III and aVF. Additionally, ST-Elevation is present in leads V1 through V4. As some readers pointed out, this is diagnostic for an Anterior Wall Myocardial Infarction. There are also some subtle hints that this is not a normal variant:

  • Dr. Smith included in the comments that the R-wave amplitude of V2-V4 is only 10 mm. In cases of AWMI, a loss of precordial R-wave amplitude is often noted.
  • If you compare the T-waves in V1 and V6, you'll note that they are much larger in V1 than in V6. Dr. Henry J. L. Marriott describes this finding as a "loss of precordial T-wave balance." Dr. Mattu covers this in depth in his excellent video New Tall T-Waves in V1.

The most important point is that there is no other explanation for our patient's ST-Elevation. There is no LVH or BBB present and Early Repolarization is a diagnosis of exclusion in a 62 year old patient.

Regardless, any patient with chest pain should be evaluated with serial ECG's. During our patient's second 12-Lead, he happened to be pain free:

Well Page Him Again - Repeat 12-Lead

Our repeat 12-Lead shows a normal sinus rhythm, with the development of terminal T-wave inversions in leads V1-V4. Several of our readers correctly pointed out that these are the hallmarks of the eponymous Wellens' Syndrome (or Wellens' Warning). Interestingly enough, the computer's interpretation now displays *** ACUTE MI ***.

Well Page Him Again - Wellens Syndrome

So what is the importance of this finding?

In 1982, Hein JJ Wellens identified two types of abnormal T-waves associated with critical, proximal LAD stenosis. The first type, not seen in our case, features deeply inverted, symmetric T-waves in the anterior precordial leads. The second type, featured above, are characterized by biphasic T-waves. In his seminal study, Wellens found that these electrocardiographic patterns were most often seen during pain free periods. Subsequent studies showed that nearly every patient with Wellens' Syndrome had blockage in the LAD, ranging from 50-100%!

So what happened with our patient?

Our patient continued to experience transient episodes of chest pain. His troponin-I levels returned at 1.09 ng/mL 20 minutes after the pain-free ECG. Recognizing Wellens' Syndrome, the ED physician had the patient transferred directly to the cath lab for immediate PCI.

Key points highlighted by this case:

  • Obtain Serial ECG's!
  • A single ECG diagnostic for STEMI is indication for cath lab activation.
  • Resolution of chest pain is not a reason to withold aspirin.
  • Wellens' Sydrome strongly suggests an advanced degree of LAD stenosis and requires urgent evaluation.

References

  • Dr. Smith's ECG Blog – Wellens' Syndrome
  • de Zwann C, Bar FW, Wellens HJJ. 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. [PubMed]
  • Parikh KS, Agarwal R, Mehrota AK, Swamy RS. Wellens syndrome: a life-saving diagnosis. Am J Emerg Med 2012; 30:255e3-255e5. [PubMed]
  • Rhinehardt J, Brady WJ, Perron AD, Mattu A. Electrocardiographic manifestations of Wellens' syndrome. Am J Emerg Med 2002; 20(7):638-43. [PubMed]
Posted by on October 5, 2012 • Filed under: ems-topics, patient-management • Tagged: , , , , , , ,

Discussion to 63 year old male: chest pain – Wellens’ Syndrome? Or something else…

1 comment

This is the discussion for 63 year old male: Chest Pain.

Many of you thought the original 12 leads showed Wellens' Syndrome. 

Lets review some key points about the T wave inversions of Wellens' for a moment:

  • They occur when an occluded artery is reperfused, spontaneously or otherwise
  • They are always recorded during a pain free period
  • They are most prominent in V2-V4, rarely extending out to V6
  • QTc is usually greater than 425
  • T wave in III is usually upright

Let's take a look at the 12 Lead:

Initially, I also thought this was Wellens'.  I decided to seek the opinion of Stephen Smith, M.D. of  Dr. Smith's ECG Blog, and with his permission, here's what he had to say:  

"I don't think this is Wellens'. I think it is benign T-wave inversion. QT on the short side, distinct J-waves, extension out to V5-V6. It is a baseline of benign TWI followed by LAD occlusion."  Indeed, the QTc in the first two 12 leads were 422 and 418 respectively.  In his experience, the QT is prolonged in Wellens', and this is one way to differentiate it from benign T wave inversion (BTWI), which normally has a QTc < 400-425."

Now for the obvious STEMI:

Due to the deterioration of the patient's condition upon arrival to the hospital, he was brought directly to the acute area. Through translators, they were able to explain that patient was working out earlier this morning and developed right shoulder pain, which prompted the first EMS response. His symptoms resolved by EMS' first arrival and he sent them away. He subsequently took a shower and again began to feel the right shoulder pain, shortness of breath and lightheadedness again, which prompted him to recall EMS.  

A hospital ECG at 10:01 revealed improvement in patient's ST elevation (no copy was retained). Heparin was administered, and the patient was moved to the cath lab. The angiogram revealed single vessel coronary artery disease. The mid LAD had 95% acute plaque disruption. A thrombectomy was performed, and a white and pink thrombus was retrieved. The artery was stented, and TIMI-3 flow was restored.  Door-to-Balloon time was 34 minutes.

Here are the before-and-after angiograms:

Posted by on June 28, 2011 • Filed under: ems-topics, patient-management • Tagged: , , , , , , ,