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I have completed bits of my EM training from India. Currently I am boarded with credentials from Christian Medical College, Vellore and also from the prestigious Royal College of Emergency Medicine, UK.  I am currently working in London as an A&E doctor, trying to appreciate the differences in the practise and culture of Emergency Medicine across different healthcare systems. I have always been an avid FOAMed supporter because FOAMed played an indispensable role during the days of my initial training. Through this blog, I aspire to disseminate knowledge and stay up to date with the EM literature. 

Monday, August 24, 2015

The widow maker lesion

Wellens' Syndrome

Wellens’ syndrome was first described by Prof Hein J.J. Wellens in 1982. It can be best described as a warning for an impending heart attack. As emergency physicians it is crucial for us to be able to recognise this ECG pattern. Recognition of this ECG pattern can potentially prevent the myocardial infarction. 

It is important to understand that Wellens’ syndrome is not just an ECG sign alone but ECG signs in context with the clinical picture illustrated below.

Identification with examples

There are 2 types of Wellens’ waves:
  • Wellens' with biphasic T waves and  - Figure 1
  • Wellens' symmetrically inverted and deep T waves – Figure 2

Figure 1 (image courtesy - Lifeinthefastlane)


Figure 2 (image courtesy: Lifeinthefastlane)

 Diagnostic criteria for Wellens:

1.   Deeply inverted or biphasic T waves in V2-V3 sometimes extending from V1 to V6
2.   Isoelectric or slightly elevated ST segment (< 1mm)
3.   No pathological precordial Q waves
4.   Preserved precordial R wave progression
5.   Recent history of Angina
6.   ECG pattern in pain free state
7.   Normal or slightly elevated serum cardiac markers

Clinical Importance
  • Signifies critical left anterior descending artery occlusion and high risk for extensive myocardial infarction
  • About 75% of patient with this ECG finding have AW STEMI within < 2 weeks. 
  • These patients may or may not have active chest pain at presentation and the cardiac enzymes may be normal or elevated
  • These patients are not fit for stress tests as they are too high risk for a large myocardial infarct
                                           
What should you do when you encounter this finding?
Get cardiology involved and push for a timely angiography. Medical Management is usually ineffective for these lesions, these are best managed with PCI.

Key Points:
  • Watch out for Wellen's waves routinely (esp biphasic T waves)
  • This subset of patients may not have chest pain and normal cardiac biomarkers.
  • Don't send them for a stress test. 
  • Discuss with Cardiology for urgent/emergent PCI

References

1. de Zwaan C, Bar FW, Wellens HJ. Characterstic electrographic pattern indicating a critical stenosis high in left anterior descending coronary artery in patients admitted because of impending myocardial infarction. Am Heart J. 1982 Apr; 103: 730-6
2.  Rhinehardt et al. Electrographic manifestations of     Wellens Syndrome. Am J of Emergency Medicine 2002 Nov; 20(7):638-43
3. Liu Mao et al. For Physicians: Never forget the specific ECG T- wave changes of Wellens syndrome. International Journal of Cardiology. 2013 July 15;167(1)
4. Tandy TK et al. Wellens’ Syndrome. Annals of Emergency Medicine. 1999 Mar; 33(3): 347-51


More Learning 
1.   lifeinthefastlane.com
2.   SSmith’s ECG Blog  
3.   Ecgweekly.com



Author
Dr. Akshay Kumar MBBS, MRCP
Twitter: @akshay2111            
Senior Resident
Department of Emergency Medicine
All India Institue of Medical Sciences
New Delhi

Edited by: Lakshay Chanana


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