wellens ’ syndrome
DESCRIPTION
Wellens ’ Syndrome. Geoff Lampard PGY-1 Jan 6 th 2011 ECG Rounds. Case 1. 5 5 yo male with history of stable angina P resents to ED with ischemic chest pain. …. pain resolves with NTG…. Serum TnT returns normal What do you see in the ECG?. Case 2. - PowerPoint PPT PresentationTRANSCRIPT
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Wellens’ SyndromeGeoff Lampard PGY-1Jan 6th 2011 ECG Rounds
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Case 1 55yo male with history of stable angina
Presents to ED with ischemic chest pain
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…. pain resolves with NTG….. Serum TnT returns normal
What do you see in the ECG?
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Case 2 57 yo male with 4/10 pressure-like chest pain
ASA, O2, 2 x SL NTG sprays with EMS
Pain now improving
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… and pain free…….
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Case 3 54M with pressure like RSCP, diaphoresis
NTG and morphine relieves pain. ECG follows:
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Now 1 minute into the stress test……
Anterior wall STEMI.
Immediately taken for cath and found an extensive proximal LAD lesion
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The widowmaker
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Wellens’ Syndrome
• First recognised in early 1980’s in a subgroup of UA patients with precordial T-wave changes in the pain free period who developed large anterior MI’s.
• All patients who met their criteria had ≥ 50% LAD stenosis
• 26/145 patients admitted for UA developed characteristic ECG findings at or within 24hrs of admission
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Key concept #1
Wellens is relatively common (14-18% of UA patients)
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• ½ way through study, medical management was aborted and all were given preferential angiography
• 75% of medically managed patients developed anterior MI’s within 3 weeks
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Key concept #2
Wellens is a preinfarction stage of CAD
Mean time to infarction: 8.5 days
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1. ECG findings:
a. Symmetric, deeply inverted T waves in V2-3. Occasionally in V1,V4-6, or
b. Biphasic T waves in V2-3 plus
c. Isoelectric or minimally elevated (<1mm) ST
2. No precordial Q-waves
3. History of angina4. Pattern in pain free
state5. Normal or slightly
elevated serum markers
Criteria
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Key concept #3
It is best seen during the pain-free period….
Get serial or pain-free ECG’s from UA patients!
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Deep Inverted (figures A-C)• ~75% of Wellens
Biphasic pattern (D-F)• ~25% of cases
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But remember, the differential for t-wave inversion is large.
• Acute ischemia• LVH• BBB• Late pericarditis• PE• CNS pathology• Myocarditis• Digitalis• Old MI• etc. etc. etc.
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Key concept #4
Patients need early angiography.
Get cardiology involved in the ED!
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Case 1, pain free
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Case 2, pain free
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Case 3, pain free….
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• Wellens’ is not uncommon.
• Remember the 2 characteristic ECG changes
• Get a pain-free ECG!
• Wellens’ is a sign of impending MI.
• Requires urgent assessment.
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Recommended further reading
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Qu
estio
ns
?
De Zwann C, Bar FW, Wellens JHH: Characteristic electrocardiographic pattern indicating a critical stenosis high in left anterior descending coronary artery in patients admitted because of impending myocardial infarction. Am Heart J 1982. 103:730-736
De Zwann C, Bar FW, Janssen JH, et al: Angiographic and clinical characteristics of patents with unstable angina showing an ECG pattern indicating critical narrowing of the proximal LAD coronary artery. Am Heart J 1989. 117:657-665
Rhinehardt J, Brady WJ, Perron AD, Mattu A. Electrocardiographic Manifestations of Wellens’ Syndrome. Am Journal Emerg Med 2002. 20:638-643.
Lilaonitkul M, Ronbinson K, Roberts M. Wellens’ Syndrome: significance of ECG pattern recognition in the emergency department. Emerg Med J. 2009. 26:750-751