All that wiggles isn’t Wellens’

This is the discussion for our Snapshot Case involving a 45 year old female complaining of chest pain.

Here is the 12 lead for review:

ECG1:16xThere is sinus rhythm at about 75 bpm. Slight ST elevation in V2. Biphasic T wave inversion in V2, inverted T waves in aVL, V3-V5.

As we recall, the patient had complained of “off and on” chest pain radiating to her left arm. Concerning to be sure! In addition, the patient was “pain free” at about the time of this 12 lead ECG.

Many of you astutely recognized the possiblity that this ECG showed the Wellens’ pattern. We know that the Wellens’ pattern typically occurs while the patient is pain free.  I was concerned that this was Wellens’ also. I did think the R waves were larger than those I’ve seen in other Wellens’ cases, but.. it sure looked like it could be Wellens’. And after all, our chest pain patient was now pain free!

Here is an example of Wellens’ (second type):

wellens

Here is V1-V6 from our patient:

wellens?

Sure looked like it could be Wellens’. The receiving doc in the ER was also concerned. Don’t you just love catching Wellens!

The patient was admitted, and labs drawn. When I followed up to see how critical the LAD lesion was, I got some interesting news: Troponins came back negative. I do not know the discharge diagnosis, but it was not ACS.

Hmph. What happened?? Wellens’ seemed so straight forward. Why wasn’t this Wellens’? I neeeeded to know!

So, I went to the most logical place for answers: Dr. Stephen Smith of Dr. Smith’s ECG Blog.

Here’s how it went:

Me: Dr. Smith, what are your thoughts on this ECG? I was concerned it was Wellens’…

DS: These are non-diagnostic T waves. Maybe ischemia, maybe not. So this is the person you would rule out with serial trops, then stress.

DS: Or do a CT coronary angiogram.

DS: This would be a good case to post as an example of not-Wellens’ waves.

So it is! I started with a good post about Wellens’, and ended up with a good post about not-Wellens’. Here’s the thing though: I am still not sure why it is not Wellens’, even though I know it is a good example of not Wellens’. I figured I better learn the objective Wellens’ criteria Dr. Smith is using!

ME: When differentiating these from Wellens’ waves, is there an objective criteria you are using?    

DS: That’s the problem. There is no objective criterion. It is all my experience.

DS: I can say I have seen hundreds if not thousands of such ECGs which are not due to ACS. Many are. That is why I say non-diagnostic.

DS: When I see a Wellens’ morphology, 80% of the time it really is ACS. Still not 100%.

Wait, What? 80%? I never heard that before! Basically, 1 out of every 5 Wellens’ pattern we catch actually won’t be Wellens’. I’ll admit, I found myself feeling a little lacking in the ECG Jedi Master department:

obewan

“These aren’t the waves you’re looking for…”

*image credit

This Snapshot case left me somewhat unsatisfied. The result was unexpected, and I didn’t feel on solid ground about the ECG. That’s how it goes sometimes with some of our cases. Not the answers we thought we’d get. We’ll just have to roll with it, and march on to the next case.

In closing, a few take home points:

  • When I become a full fledged ECG Jedi Master, this ECG will obviously be not-Wellens’.
  • In the meantime, we must know that all that wiggles isn’t Wellens’. Even with a good story. Keep your guard up, but also know the limitations.

Thank you to Dr. Smith for again providing his wisdom and invaluable insights. As always, comments welcome!

 

4 Comments

  • Andrew Przepioski says:

    Nice follow up. Didn’t know that about Wellens.

  • Charles Spencer says:

    Interesting they took the patient straight to the lab. In my area we treat suspected wellen’s the same as high risk non-STE ACS e.g. load DAPT, serial ECGs, monitor, TNIs, IV GTN if needed. We only take them to the lab if they are shown to be unstable e.g. ongoing chest pain despite IV GTN or further ECG changes – true wellen’s may have STE when in pain.

    In reference to the ECG, I don’t have the Jedi master thing yet either but generally in Wellen’s changes are most pronounced V1-3. This looks like shallow T wave inversion V2-5 with slight STE/biphasic T V2-3, and would agree it is non-specific. With the history would still have ACS at the top of the differential though.

  • Gary Huntress says:

    Not to nitpick but is this really a “slightly leftward axis”? I and AVF are both positive. I put it at about +20 degrees, not leftward.

  • David Baumrind says:

    @Gary, by all means, nitpick all you like. I agree with your assessment, and the post has been modified.

    Thank you for the feedback!

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Comments
Ken Grauer, MD
The 360 Degree Heart – Part II
Nice case Vince (!) - as you lay the ground for your "pet concept" of the vector approach to ST elevation. That said, for those vectorially-challenged readers (like myself) - I offer the following 2 concepts: i) This is not diffuse subendocardial ischemia because the ST depression is not "diffuse". Instead - there is no…
2014-10-26 05:13:56
Stephen Smith
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2014-10-24 16:14:36
Kevin
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2014-10-22 13:31:06
Vince DiGiulio
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It is standard practice in electrocardiography to label the first 90 degrees counter-clockwise from "zero" that way. When you see a patient with "left axis deviation" you'll see that their measured QRS axis is somewhere between -30 and -90 degrees. Imagine if you saw someone with a mean QRS axis at 5 degrees. Now imagine…
2014-10-21 14:00:37
Bryan
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I don't understand why (-)III and aVL are be labeled -60 and -30 degrees instead of 300 and 330 degrees?
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