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A warning sign

Published:August 20, 2016DOI:https://doi.org/10.1016/j.ejim.2016.08.012

      Abstract

      A 64 year old man presented with atypical chest pain of 6 h duration. Physical examination showed tachycardia and an irregularly irregular pulse. Initial EKG showed atrial fibrillation with rapid ventricular rate. Intravenous Diltiazem was administered following which there was resolution of atrial fibrillation as well as his chest pain. Troponin T and CPK-MB were minimally elevated at 0.05 ng/ml (0.0–0.03 ng/ml) and 8.6 ng/ml (0.0–7.0 ng/ml) respectively. A repeat EKG obtained after symptom resolution showed biphasic T wave inversions in V2 and V3 which prompted an emergent coronary angiogram that revealed 90% occlusion of the proximal LAD. The immediate recognition of Wellens' pattern lead to emergent coronary revascularization and prevention of acute myocardial infarction in our patient. Clinicians should be aware of this syndrome so that prompt invasive therapy can be done to avoid evolution into MI and subsequent left ventricular dysfunction.

      1. Introduction

      A 64 year old man with hypertension and no prior history of coronary artery disease presented with atypical chest pain of 6 h duration. Physical examination was significant for tachycardia and an irregularly irregular pulse. Initial EKG showed atrial fibrillation with rapid ventricular rate for which IV Diltiazem was administered. He reported complete resolution of chest pain following that. Troponin T and CPK-MB were minimally elevated at 0.05 ng/ml (0.0–0.03 ng/ml) and 8.6 ng/ml (0.0–7.0 ng/ml) respectively. A repeat EKG was done during which time the patient was completely chest pain free. The findings on that EKG (Fig. 1) prompted an emergent coronary angiogram that revealed 90% occlusion of the proximal LAD for which a drug eluting stent was placed. Left ventriculogram done at that time showed normal left ventricular function. He was discharged with dual antiplatelet therapy for one year and was doing well at his cardiology outpatient follow up.
      Fig. 1
      Fig. 1EKG showing normal sinus rhythm and biphasic T wave inversions in V2 and V3.
      What is the diagnosis?

      2. Diagnosis

      The immediate recognition of Wellens' pattern lead to emergent coronary revascularization and prevention of acute myocardial infarction (MI) in our patient. The criteria for the syndrome include biphasic or inverted T-wave changes in precordial leads, history of anginal chest pain, normal or minimally elevated cardiac enzyme levels, EKG without Q waves or significant ST-segment elevation and with normal precordial R-wave progression [
      • Tatli E.
      • Aktoz M.
      • Buyuklu M.
      • Altun A.
      Wellens' syndrome: the electrocardiographic finding that is seen as unimportant.
      ]. There are 2 types of Wellens' pattern described. Biphasic T waves which account for 25% of cases are termed Type A and the inverted T waves are termed Type B which is more common, accounting for 75% of the cases [
      • Mao L.
      • Jian C.
      • Wei W.
      • Tianmin L.
      • Changzhi L.
      • Dan H.
      For physicians: Never forget the specific ECG T-wave changes of Wellens' syndrome.
      ]. Wellens' syndrome has been reported to occur in 14% to 18% of patients presenting with unstable angina [
      • De Zwaan C.
      • Bar F.W.
      • Wellens H.J.
      Characteristic electrocardiographic pattern indicating a critical stenosis high in left anterior descending coronary artery in patients admitted because of impending myocardial infarction.
      ]. The T-wave changes in the syndrome typically occur during a chest pain-free interval. These patients fare poorly with conservative therapy. This is evidenced by Wellens' initial study which showed that 75% of patients with this syndrome who did not receive coronary revascularization developed extensive anterior wall MI within a few weeks after admission [
      • De Zwaan C.
      • Bar F.W.
      • Wellens H.J.
      Characteristic electrocardiographic pattern indicating a critical stenosis high in left anterior descending coronary artery in patients admitted because of impending myocardial infarction.
      ]. Stress testing is absolutely contraindicated as increasing cardiac demand with a highly stenosed LAD may lead to MI. Clinicians should be aware of this syndrome so that prompt invasive therapy can be done to avoid evolution into MI and subsequent left ventricular dysfunction.

      Conflict of interest

      The authors declare no conflicts of interest.

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