Wellen's Syndrome: Is One Electrocardiogram Good and Plenty?

Abstract

The authors present a case of Wellen's syndrome, which has a characteristic T-wave on an electrocardiogram during a pain-free period in a patient with intermittent chest pain. The clinical presentation, pathophysiology, and management is discussed, and the importance of obtaining more than one electrocardiogram (ECG) is explained. What this case adds to the literature is the fact that Wellen’s syndrome patients may present atypically with active chest pain and, as such, should be managed similarly to acute myocardial infarction patients. However, because the diagnosis of Wellen’s syndrome depends on an ECG obtained during the ensuing pain-free period, serial ECGs are usually required to reveal T-wave abnormalities in this context and have been shown to be disposition-altering in the Emergency Department (ED). Support for the death-denying outcome preferred in Wellen’s syndrome by patients and providers alike depends on recognizing the diagnosis and consulting cardiology expediently.

Wellens Syndrome: A Possible Precursor

“…Still, in an ideal world and at the peak of the COVID-19 era, few patients received such prompt percutaneous intervention. Post-catheterization outcomes have also been very successful for those who received these quick interventions, but a delay in intervention may lead to anterior wall infarction and, in some cases, death [5][6][7][8][9]12].…”

Wellens syndrome

“…Although most clinicians can detect overt ECG signs of ischemia when present, a false sense of security can set in when the initial ECG appears normal. The caveat in Wellens syndrome is that many patients have a normal-appearing ECG during chest pain and only exhibit the characteristic ECG patterns when they are pain-free 1,12,15. If the pain returns, pseudo-normalization of the ECG can occur as precordial T-wave morphology changes from inverted to upright 2.…”

Síndrome de Wellens. Reporte y revisión de un caso

“…17 Schears MR and collaborators, describe the evolution of these patterns starting with biphasic T waves (pattern A) that are deeply and symmetrically reversed (pattern B). Then it extends to V4, then to V5 and finally to V6, not documented in all cases by lack of serial electrocardiograms, 21 without defining the time in which one pattern can change to another. Atypical cases have been described where the type B pattern changes to type A.…”

“…Atypical cases have been described where the type B pattern changes to type A. 22 It should be emphasized that changes in the T wave occur during periods without precordial pain and pseudo normalized during the precordial pain episode, and may persist for hours or weeks 7,23 leading to errors in diagnosis and inadequate risk stratification, so the ability to recognize these patterns is extremely important, since ECG changes can be subtle [8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24] There are atypical presentations in which there is no precordial pain, only syncope, but the electrocardiographic pattern meets WS criteria. 25 In the case presented, the fact that the patient was asymptomatic at the time of admission to the emergency department, and the taking of an initial electrocardiogram as part of the cardiology evaluation, showed the inversion of T waves in precordial leads from V2 to V6, leading to timely diagnosis confirming it with pseudonormalization during an episode of precordial pain, which occurred spontaneously without maneuvers to cause ischemia.…”