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The Cardiology registrar has just reviewed your patient who earlier had a bout of what seemed like ischaemic sounding chest pain, though the ECG appeared relatively reassuring and the cardiac enzymes were minimally elevated. The registrar, however, midway through his review turned pale and ran out of your unit clutching the patient’s ECG screaming something along the lines of “I’ll get the boss. This guy’s got Wellen’s syndrome” |
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What is Wellen’s syndrome and why does it matter?
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Wellen’s syndrome is the occurrence of characteristic T-wave patterns in the setting of ischaemic chest pain with no or minimal elevation of cardiac biomarkers. It is indicative of a high risk proximal LAD stenosis -> 100% of patients with a true Wellen’s syndrome have >50% LAD stenosis. Do not subject these patients to an exertional stress test as they are at high risk of a devastating anterior wall infarct and potentially a VF / pulseless VT cardiac arrest.
There are 2 characteristic ECG patterns, which typically emerge once the chest pain has resolved; so serial ECGs are key and having a baseline ECG can also be a great help as the changes can be subtle.
The first pattern (75% of cases) is T-wave inversion from V1-4 and occasionally extending to V5 and 6, which can be strikingly deep, with little (<1mm) or no ST elevation. V1 is involved in 66% of ECGs and V4 in 75% of ‘Wellenoid’ ECGs.
There are no Q-waves and the precordial R-wave progression is usually normal.
The second pattern (25% of cases) is biphasic T-waves, in V2-3 and can involve V1 and V4 – 6, with little (<1mm) or no ST elevation.
The cardiac biomarkers are often normal, but if raised, rarely reach twice normal values.
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All 3 sites have good ECGs demonstrating the 2 patterns
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