Tuesday, October 15, 2013

Wellen's Syndrome... an EKG Finding Not to Miss!

Let's say you're working away in the emergency department and you see a 35 year old man complaining of chest pain for about 2 hr. He does not have a significant PMHx, he is mildly obese and smokes a pack a day, the history is not totally convincing for ACS and when he arrives to the ED the pain has resolved. Sounds familiar...? - We probably see a 10 of those per shift! The protocol says, everyone who says the words "chest" and "pain" in the same sentence gets an ECG at triage. The nurse brings it to you and this is what you see.. (sorry for the shadows, but I couldn't find the right angle)

Hmmmm... A 10 second view shows sinus rhythm, a little slow, the voltages are a bit low in the limb leads. There are some ST-T changes that don't look quite right with T wave inversions in the anterior and lateral leads, with similar milder changes in the inferior leads. The J point seems to be isoelectric and there is some "eyeballed" QT prolongation (R to R seems longer than the twice the length of the QT). The protocol also says that in the absence of contraindications everyone gets hooked to the monitor, oxygen by nasal cannula, aspirin, labs, CXR, maybe NTG. (Yes, I know, and before you start going at it, I am trying to change that oxygen mandate in my department; but it is hard to change protocols!) You do a physical exam which, as in most cases, does not reveal anything significant. Few minutes later the labs come back with negative cardiac markers, his CXR looks fine and he remains pain free. The repeat EKG looks like this... The changes practically resolved!

Now what?! What's the deal here? This dude has dynamic EKG changes, but he is pain free, markers are normal, and now everything seems to be OK. Right? - WRONG! This guy is in deep doo-doo if you don't do the right thing. And the reason you should be scared is b/c he has Wellen's syndrome

Wellen's syndrome is an electrocardiographic phenomenon seen in critical obstruction of the LAD. Described in the 1980's, Wellen's has 2 types, type 1 has biphasic T wave in leads V1-V4, with the type 2 having deep T waves inversions. Other characteristics are no precordial Q wave and no loss of R wave progression. (Here is a type 2, note the deep TWI in anterior leads)

So, what happened to our patient? - I called cardiology and said something like this: "Sir, I have a 35 y/o with Wellen's, currently chest pain free, with negative cardiac markers. Do you want to see him here in the ED or in the CCU?" The cardiologist seemed to be in a good mood that day and didn't give me any grief. Patient went up to CCU and booked for cath the next day.

Now, putting it all together. What you need to know about Wellen's

- Recognize the pattern of biphasic T wave or deep inverted T waves in V1-V4
- It means high degree of obstruction in the LAD
- DO NOT send this patients for stress test. It will precipitate an AMI
- These patients need admission and early revascularization
- Do not miss it. This is a "pre-infarct" phenomenon. If the patient goes home, he/she will progress into an anterior MI, and that is considered not good.

For more reading...

- de Zwann C, Bar FW, Wellens. Characteristic electrocardiographic pattern indicating a critical stenosis high in the left anterior descending coronary artery in patients admitted because of impending myocardial infarction. Am Heart J. 1982; 103:730-736
- Tandy TK, Bottomy DP, Lewis JG. Wellen's syndrome. Ann Emerg Med 1999; 33:347-351 (http://www.ncbi.nlm.nih.gov/pubmed/10036351)
- Rhinehardt J, Brady WJ, Perron AD, Mattu A. Electrocardiographic manifestations of Wellens' syndrome. Am J Emerg Med. 2002; 20:638-643. (http://www.ncbi.nlm.nih.gov/pubmed/12442245)

In honor of Dr Wellens

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