Wellens' Syndrome: Is it on your radar?


Wellen’s Syndrome was first described in 1982 in which 75% of patients with t wave inversions in V2-V4 went on to have an acute myocardial infarction (MI). This was again repeated in 1989, and showed that all patients with this morphology had >50% LAD stenosis. The incidence in the United States is about 10-15%. 

What is Wellens' Syndrome?
This is a preinfarction stage of coronary artery disease, also referred to as LAD coronary T-wave syndrome. The syndrome criteria include the following:
  • History of angina + T wave inversion or biphasic t waves in V2–V4 
  • Normal or minimally elevated cardiac enzymes 
  • No pathologic precordial q waves or loss of precordial R wave progression 

What are the types of Wellens' Syndrome?
There are two types: Type 1 (75% of cases) and Type 2 (25% of cases)


    Why does Wellens' Syndrome matter?
    It signifies a critical high grade proximal LAD stenosis.
    • Acute MI occurs within a mean of 6 - 8.5 days after admission
    • Acute MI occurs within a mean of 21.4 days after symptoms
    • Note: Exercise stress testing can be fatal due to severe stenosis (case reports)

    What is the specificity of inverted T waves (V1–V4) on EKG for proximal LAD stenosis? 
    Kojuri et al took 130 patients with known proximal LAD >70% stenosis on angiography and retrospectively went back to look at the most specific EKG findings associated with this anatomic lesion. The MOST SPECIFIC predictor of a proximal LAD lesion was, inverted or biphasic T waves in leads V1 - V4 at 91.6% (sens 70.8%, PPV 70.5%).

    How do you treat Wellens' Syndrome?
    Early revascularization is superior to medical management.
    • 26.7% of patients treated medically die from cardiovascular cause
    • 0.7% of patients treated with revascularization die from cardiovascular cause



    The T-wave changes of Wellens' Syndrome may be transient, may persist for months or might resolve with medical treatment. These patients are at extremely high risk of anterior wall MI.

    Bottom Line: 
    Wellens' Syndrome signifies a proximal LAD lesion that requires admission with early revascularization to prevent acute MI.



    Salim Rezaie, MD
    (@srrezaie)
    Clinical Assistant Professor of EM and IM
    University of Texas Health Science Center at San Antonio

    References
    1. De Zwaan C et al. Angiographic and Clinical Characteristics of Patients with Unstable Angina Showing an ECG Pattern Indicating Critical Narrowing of the Proximal Coronary Artery. Am Heart J 1989 Mar; 117 (3): 657–65. PMID: 2784024
    2. De Zwaan C et al. 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 Apr 102(4): 730–6. PMID: 6121481
    3. Hanna EB et al. ST-Segment Depression and T-Wave Inversion: Classification, Differential diagnosis, and Caveats. Clev Clin J Med 2011 Jun; 78(6): 404–14. PMID: 21632912
    4. Kojuri J et al. Electrocardiographic Predictors of Proximal Left Anterior DescendingCoronary Artery Occlusion. Cent Eur J Med 2009 Sept; 3 (3): 294 – 99. 
    5. Mead NE et al. Wellen’s Syndrome: An Ominous EKG Pattern. J Emerg Trauma Shock. 2009; 2(3): 206–8. PMC: 2776372
    6. Simon K et al. The Natural History of Post Ischemic T-Wave Inversion: A Predictor of Poor Short-Term Prognosis? Coron Artery Dis 1994; 5: 937–42. PMID: 7719526