IMAGES
IN THE
MEDICAL SCIENCES
Omen of Infarction: Wellens’ Sign Faraz K. Luni, MD, Ankush Moza, MD, Abdur R. Khan, MD and George V. Moukarbel, MD* *Division of Cardiovascular Medicine, University of Toledo Medical Center, Toledo, Ohio (E-mail: [email protected]) The authors have no financial or other conflicts of interest to disclose.
FIGURE 1
A
53-year-old woman with hypertension and diabetes presented to our emergency room with a 2-day history of intermittent episodes of right-sided chest pain radiating to the right shoulder and back. On initial evaluation, the physical examination, electrocardiogram (ECG) and cardiac enzymes were unremarkable. A follow-up
ECG obtained several hours later revealed anterolateral symmetric T-wave inversion consistent with Wellens’ sign (Figure 1). Interestingly, the patient was free of chest pain since admission, and the follow-up troponin levels were only mildly elevated at 0.05 ng/mL (reference range, 0.00–0.04 ng/mL). Urgent cardiac catheterization was performed, which revealed a critical 99% stenosis of the proximal left anterior descending coronary (LAD) artery (Figure 2), and was successfully treated by percutaneous intervention. Wellens’ syndrome was described in 1982 as “a typical pattern of ST-T segment in leads V2 and V3 consisting of an isoelectric or minimally elevated (1 mm) takeoff of the ST segment from the QRS complex, a concave or straight ST segment passing into a negative T wave at an angle of 60 to 90° and a symmetrically inverted T wave.”1 The authors indicated these changes to be suggestive of a critical lesion of the proximal segment of the LAD. The caveat of utmost importance is that patient usually present with unstable angina and minimal or no elevation of cardiac enzymes, and the typical ECG changes are seen when they are free of chest pain. This may lead to inappropriate referral for a stress test instead of cardiac catheterization, which can lead to fatal arrhythmias or myocardial injury.2 Thus, widespread awareness of this syndrome among internists and emergency physicians is crucial for the appropriate management of these patients. REFERENCES 1. de Zwaan C, Bär FW, Wellens HJ. 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;103:730–6.
FIGURE 2
218
2. Sowers N. Harbinger of infarction: Wellens syndrome electrocardiographic abnormalities in the emergency department. Can Fam Physician 2013;59:365–6.
The American Journal of the Medical Sciences
Volume 350, Number 3, September 2015
IN THE
MEDICAL SCIENCES
Omen of Infarction: Wellens’ Sign Faraz K. Luni, MD, Ankush Moza, MD, Abdur R. Khan, MD and George V. Moukarbel, MD* *Division of Cardiovascular Medicine, University of Toledo Medical Center, Toledo, Ohio (E-mail: [email protected]) The authors have no financial or other conflicts of interest to disclose.
FIGURE 1
A
53-year-old woman with hypertension and diabetes presented to our emergency room with a 2-day history of intermittent episodes of right-sided chest pain radiating to the right shoulder and back. On initial evaluation, the physical examination, electrocardiogram (ECG) and cardiac enzymes were unremarkable. A follow-up
ECG obtained several hours later revealed anterolateral symmetric T-wave inversion consistent with Wellens’ sign (Figure 1). Interestingly, the patient was free of chest pain since admission, and the follow-up troponin levels were only mildly elevated at 0.05 ng/mL (reference range, 0.00–0.04 ng/mL). Urgent cardiac catheterization was performed, which revealed a critical 99% stenosis of the proximal left anterior descending coronary (LAD) artery (Figure 2), and was successfully treated by percutaneous intervention. Wellens’ syndrome was described in 1982 as “a typical pattern of ST-T segment in leads V2 and V3 consisting of an isoelectric or minimally elevated (1 mm) takeoff of the ST segment from the QRS complex, a concave or straight ST segment passing into a negative T wave at an angle of 60 to 90° and a symmetrically inverted T wave.”1 The authors indicated these changes to be suggestive of a critical lesion of the proximal segment of the LAD. The caveat of utmost importance is that patient usually present with unstable angina and minimal or no elevation of cardiac enzymes, and the typical ECG changes are seen when they are free of chest pain. This may lead to inappropriate referral for a stress test instead of cardiac catheterization, which can lead to fatal arrhythmias or myocardial injury.2 Thus, widespread awareness of this syndrome among internists and emergency physicians is crucial for the appropriate management of these patients. REFERENCES 1. de Zwaan C, Bär FW, Wellens HJ. 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;103:730–6.
FIGURE 2
218
2. Sowers N. Harbinger of infarction: Wellens syndrome electrocardiographic abnormalities in the emergency department. Can Fam Physician 2013;59:365–6.
The American Journal of the Medical Sciences
Volume 350, Number 3, September 2015
