Written by Vivian Lei
Biphasic or deep precordial T waves on ECG can occur with spontaneous reperfusion of an occluded left anterior descending artery and should not be ignored in the patient with chest pain.
Why does this matter?
Can you recognize the Wellens’ syndrome ECG pattern? We’ve covered this ECG pattern before, but it’s worth a refresher. An acute MI may be imminent.
But the chest pain is gone…
In this NEJM case report, a 58-year-old man presented to an emergency department with 1 day of intermittent chest pain. In the ED, his chest pain had resolved and his first ECG (A) showed biphasic T waves in leads V1 and V2 and inverted T waves in V3 and V4. He had an elevated troponin T level of 0.41 ng/mL (ref <0.1). After cardiology consultation, a cardiac catheterization was scheduled for later that day. After 80 minutes, the patient began having chest pain and a repeat ECG (B) showed ST-segment elevations in leads V1 through V6 as well as I and aVL. He had an emergency coronary angiography that showed a complete occlusion of the proximal left anterior descending artery, and a stent was placed.
This ECG pattern of deep or biphasic precordial T wave inversions, usually in V2 and V3, can be seen during a pain-free period after spontaneous reperfusion of an occluded left anterior descending artery. Immediate cardiology consultation for coronary angiography should be performed due to risk of coronary re-occlusion by unstable plaque.
Wellens’ Syndrome. N Engl J Med. 2022 Sep 22;387(12):e25. doi: 10.1056/NEJMicm2201699.