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

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:

4 Comments

  • Dominick says:

     
    With all due respect to the good Doctor, I'm going to have to go ahead and disagree.
     
    The morphology of the biphasic T-wave in lead V3 appears consistent with Wellens Warning. It meets all the diagnostic criteria set forth in literature (Wellens Syndrome, Annals of Emergency Medicine, March 1999, Vol.33, No. 3, pp347-351)(Intern Emerg Med. "The Wellens' Syndrome in the management of acute coronary syndromes", May 7,2012)(Cardiology Journal. 2009;16(1):73-5). As far as I'm aware, the lack of a prolonged QT has never been a rule out for Wellen's. The finding of Wellens' Syndrome, in this case, seem to be supported by the development of an anteroseptal infarct.
     
    If you have any documentation or literature supporting the use of QTc as exclusionary criteria, I'd be interested in taking a read.

  • FLMedic311 says:

    Criteria for Wellens is as follows.
    -prior history of chest pain
    -little to no cardiac enzymes elevation
    -no pathological precordial Q waves
    -little to no ST segment elevation
    -no loss of precordial R wave progression
    -Biphasic T waves in leads V2and V3 or symmetric, often deeply inverted
    T waves in leads V2 and V3

    Tandy TK, Bottomy DP, Lewis JG: Wellens’ syndrome. Ann Emerg Med March 1999;33:347-351

  • No paper yet has compared Wellens to Benign T-wave inversion. They both fit the criteria given.  So Tandy et al, nor de Winter et al. will help you with this.

    All I can say is that from vast experience, this ECG does NOT look like Wellens' if you look closely and you know the morphological differences between Wellens and Benign T-wave inversion (BTWI), which go far beyond QTc.  This case is still very unlikely to be Wellens'. 

    Yes, the clinical situation alone tells you it is angina and that there is a stenotic artery.  The ECG does not.  It is very likely the patient's baseline ECG with benign T-wave inversion.  QTc is only one of many factors.  No, it has never been formally studied.  I am in the process of studying it and have collected 101 cases of BTWI.  None of the many many cases of PROVEN Wellens' I have seen have this morphology.  There are two ways to prove Wellens: 1. see the patient's baseline ECG; if no T-wave inversion, then this is probably Wellens'.  2. Look for evolution on successive ECGs.  If there is the typical evoluation of deeper and more symmetric T-waves, then it is Wellens'  Unfortunately that would be complicated by the PCI, which by itself could cause Wellens' syndrome. 

    Do you have subsequent ECGs ?  Previous ECG?

    In this case, it doesn't matter because his symptoms tell you he is in trouble.  When it helps is if the patient is 40 years old and has less typical chest pain.  It really helps to recognize this morphology as a BENIGN one.  Then you won't be sending people to the cath lab unnecessarily.  But you must be an expert in differentiating these two to do it.

    Here is BTWI:

    http://www.hqmeded-ecg.blogspot.com/search/label/Benign%20T-wave%20Inversion

    http://hqmeded-ecg.blogspot.com/2012/03/benign-t-wave-inversion.html

     

    Here is classic Wellens':

    http://www.hqmeded-ecg.blogspot.com/search/label/Wellens%27%20syndrome

    And its evolution:

    http://hqmeded-ecg.blogspot.com/2011/03/classic-evolution-of-wellens-t-waves.html

  • David Baumrind says:

    Thank you for your contributions Dr. Smith… 

    Unfortunately, these are the only ECGs available for this case.

     

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