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: