Can You Spot Wellen’s Syndrome?

Written by Rick Ramirez

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For patients presenting to the ED with chest pain and ECG with evidence of biphasic T-waves in leads V2 and V3, Wellen’s Syndrome should be in in your differential diagnosis.

Why does this matter?
Chest pain is one of the most frequent presenting complaints in adult patients who present to the ED. Previously dubbed “the widow maker” or “LAD occlusion syndrome,” Wellen’s is an ECG pattern you need to know. With unstable angina patients, this syndrome is often under-recognized. The outcomes of Wellen’s Syndrome are unfavorable, with a high incidence of recurrent symptoms. It may rapidly progress to an anterior wall infarction if left untreated due to lesions in the proximal LAD.

Well… this EKG looks like Wellen’s
This single case study documents the case of a 34 y.o. male who presented to the ED after 12 hours of chest pain without other symptoms. He had a pertinent history of smoking, but no family history of heart disease. He had normal vitals, and heart sounds had no murmurs or gallops. His ECG is below.

It revealed biphasic T waves in V1–V4 with minimal ST elevation in V3, indicating Wellen’s syndrome. He was taken to the cath lab, had intervention on a 100% occlusion of the LAD, and was discharged home in stable condition.

Criteria for diagnosing Wellens’ syndrome include all of the following (86% PPV):

• Type A – Biphasic T-waves in V2 and V3

• Type B – Deep and symmetrical T-wave inversions in V2 and V3

• ECG without Q-waves and no significant ST segment elevation, with normal precordial R-wave progression

• History of anginal chest pain

• Normal or minimally elevated cardiac biomarkers

In the original study, 75% of the patients who had Wellen’s syndrome developed extensive anterior wall myocardial infarction a few weeks after admission. It also reported that the Wellen’s syndrome ECG finding indicates LAD total or near-total occlusion. Therefore, angiography and revascularization are strongly recommended.

Another Spoonful

• LITFL has THE epic post on Wellen’s.

• See also Dr. Smith’s blog on Wellen’s and a mimic.

• Also emDOCs has a great didactic post on Wellen’s.

Source
Wellen’s Syndrome: The Life-Threatening Diagnosis. Circulation. 2019 Nov 26;140(22):1851-1852. doi: 10.1161/CIRCULATIONAHA.119.043780. Epub 2019 Nov 25.

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