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Atypical chest pain with precordial T wave inversions

Published:October 10, 2020DOI:https://doi.org/10.1016/j.ejim.2020.09.012

      Keywords

      Case Description

      A 74-year-old woman with a prior history of coronary artery disease presented to the emergency department with intermittent, burning epigastric pain. Five months prior, she had a stress echocardiogram that showed no signs of ischemia. On presentation, her cardiac exam was normal, chest auscultation revealed wheezes, and the chest wall was tender. Her chest pain resolved on admission. A complete blood count, comprehensive metabolic panel, and serial troponin levels were normal. Serial 12-lead electrocardiograms (ECGs) demonstrated dynamic T wave inversions in the precordial leads, most notably in leads V2-V3 (Figure 1A-B). Because her presentation was atypical, the patient underwent a stress dobutamine echocardiogram which showed no signs of ischemia. An upper endoscopy was unremarkable. What is the most likely diagnosis?
      Figure 1
      Figure 1Serial 12-lead electrocardiograms (ECGs) captured 8 hours apart showed sinus rhythm with dynamic T wave changes in the precordial leads, most notably in leads V2-V3. A) ECG in the presence of chest pain. B) ECG in the absence of chest pain.

      Discussion

      Diagnosis: obstructive coronary artery disease
      The patient's ECG showed precordial T wave inversions (Figure 1B) and her clinical picture was suggestive of Wellens syndrome. However, a stress echocardiogram was normal, and the patient was initially discharged. Two days later, she was readmitted with worsening epigastric discomfort. Her troponins were mildly elevated, and an ECG showed anterior and inferior T wave inversions. She underwent cardiac catheterization, which revealed left anterior descending (LAD), right coronary, and left circumflex artery lesions. Her symptoms resolved after coronary artery bypass grafting.
      Wellens syndrome can be challenging to diagnose. It is defined by deeply inverted or biphasic T waves in V2-3 (which may extend to V1-6) and normal to slightly elevated cardiac markers.[
      • Rhinehardt J
      • Brady WJ
      • Perron AD
      • Mattu A
      Electrocardiographic manifestations of Wellens syndrome.
      ] Notably, patients do not have active chest pain, signs of acute anterior wall myocardial infarction, precordial Q waves, or loss of R waves.
      • Rhinehardt J
      • Brady WJ
      • Perron AD
      • Mattu A
      Electrocardiographic manifestations of Wellens syndrome.
      These changes reflect an obstruction in the proximal LAD coronary artery and are highly specific for an imminent anterior wall myocardial infarction, warranting further investigation.
      • Rhinehardt J
      • Brady WJ
      • Perron AD
      • Mattu A
      Electrocardiographic manifestations of Wellens syndrome.
      ,
      • de Zwaan C
      • Bar 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.
      False negative results in stress echocardiography can be caused by inadequate stress, concomitant antianginal treatment, left circumflex disease, limited image quality, and hyperdynamic wall motion during testing, which can hide ischemia because hyperkinetic non-ischemic walls mask the movement of hypokinetic ischemic walls.
      • Marwick TH
      Stress echocardiography.
      This case is an important reminder than when evaluating chest pain, no non-invasive test definitively rules out ischemia.

      Submission declaration and verification

      The authors have not published, posted, or submitted any related papers from this same study.

      Contributors

      SK provided care to the patient. We all contributed to the search and review of the literature. We all collaborated on writing the manuscript and selecting the figures.

      Disclosures

      The authors have no conflicts of interest to disclose.

      Acknowledgements

      The authors wish to thank Dr. Eva Luderowksi for assistance with case preparation and writing and thank Dr. Sammy Zakaria for critical review of this manuscript.

      References

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        • Brady WJ
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        Electrocardiographic manifestations of Wellens syndrome.
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        • de Zwaan C
        • Bar 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.
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        • Marwick TH
        Stress echocardiography.
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