Wellens’ Syndrome

A 54-year-old man presented with chest tightness and cold sweat for two hours. He had recurrent episodes of sudden onset chest pain for two weeks. In each event, the pain was tight in quality, constant, non-radiating, located over the substernal area, and lasting for several minutes. One day prior, he noticed the pain at the same site as that of previous episodes, and also experienced cold sweats. On the morning of the day of presentation, he had no chest pain, but felt worried and visited our outpatient clinic. His past medical history included uncontrolled diabetes. On examination, his cardiac examination was normal, and lungs were clear to auscultation bilaterally. An electrocardiogram showed a biphasic T-wave inversion in V2 to V4 (Figure 1A). Troponin I was 0.054 ng/ml. Based on the history and ECG changes, Wellens’ syndrome was suspected. Coronary angiography showed 90% occlusion of the proximal left anterior descending artery (LAD) (Figure 2), and percutaneous coronary intervention (PCI) was performed for the lesion. The ECG showed significant changes, especially the depth of the T wave, which was noticeable at one hour (Figure 1B) and two hours (Figure 1C) after the presentation, and at 24 hours (Figure 1D) after the PCI. The patient was successfully treated and finally discharged. Wellens’ syndrome is a preinfarction condition of coronary artery disease, associated with the characteristic change in ECG. The infrequent type of Wellens’ syndrome is described by a pattern of the biphasic T wave in V2 through V3, occasionally in V4, V5 and V6, on ECG associated with fatal LAD obstruction in patients with unstable angina. 1 de Zwaan C Bär FW Wellens HJ. Characteristic electrocardiographicpattern 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 Crossref PubMed Scopus (279) Google Scholar As reported, 60 percent of patients diagnosed with Wellens’ syndrome had the typical ECG changes on admission. 1 de Zwaan C Bär FW Wellens HJ. Characteristic electrocardiographicpattern 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 Crossref PubMed Scopus (279) Google Scholar In a recent report, the typical ECG sign shows very high specificity of 96.2% with sensitivity of 24.6% for predicting LAD occlusion. 2 Kobayashi A Misumida N Aoi S et al. Prevalence and clinical implication of Wellens’ sign in patients with non-ST-segment elevation myocardial infarction. Cardiol Res. 2019; 10: 135-141 Crossref PubMed Google Scholar Interestingly, as in this case, abnormalities of ST-T wave can normalize during the anginal attacks. 3 Rhinehardt J Brady WJ Perron AD et al. Electrocardiographic manifestations of Wellens' syndrome. Am J Emerg Med. 2002; 20: 638-643 Abstract Full Text Full Text PDF PubMed Scopus (113) Google Scholar Hence, the ECG change can be seen in sensation-free patients, which is of great clinical significance. Physicians should be aware of the time discrepancy between clinical manifestation and ECG change in this specific condition in the context of unstable angina. Figure 2 View Large Image Figure Viewer Download Hi-res image