What is Wellens’ syndrome?

What is Wellens’ syndrome?

The original description of Wellens’ syndrome dates back to 1982 in which they identified a subgroup of patients admitted with unstable angina who are at high risk of development of an extensive anterior wall myocardial infarction. These patients with critical stenosis high in the left anterior descending coronary artery, had characteristic ST-T segment changes in the precordial leads on or shortly after admission. They noted this finding in 26 of their 145 patients admitted because of unstable angina. In spite of symptom control with nitroglycerine and beta blockade, 12 of the 16 patients who were not operated upon developed extensive anterior wall myocardial infarction within a few weeks of admission [1].

Wellens’ syndrome has also been called LAD coronary syndrome, LAD coronary T-wave syndrome and widow maker by others, for obvious reasons [2,3]. Wellens’ syndrome has been classified into type A and type B. Type A is characterized by biphasic T waves in leads V2 and V3 while type B is characterized by deep T wave inversion in the same leads. It is notable that the ECG changes of Wellens’ syndrome are recorded during pain-free state [2].

Some have also described criteria for Wellens’ syndrome as: T wave changes plus history of angina without serum marker abnormalities, lack of Q waves and significant ST segment elevation, and normal precordial R wave progression [3].

Pseudo-Wellens’ syndrome due to cocaine associated coronary vasospasm has also been described, which has been called as a phenocopy of Wellens’ syndrome [4]. Importance of recognizing this is because use of beta blockers could be harmful in coronary vasospasm and should not be used in the treatment of cocaine induced myocardial ischaemia [5].

Other differential diagnoses for Wellens’ pattern are takotsubo cardiomyopathy, persistent juvenile T wave pattern and ECG changes associated with intracranial hemorrhage. Though the original report from Wellens’ group implied use of early coronary artery bypass grafting, in the current interventional era, most cases would be treated by percutaneous coronary intervention [6].

References

1. de Zwaan C, Bär FW, Wellens HJ. 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;103(4 Pt 2):730-6. doi: 10.1016/0002-8703(82)90480-x. PMID: 6121481.
2. Al-Assaf O, Abdulghani M, Musa A, AlJallaf M. Wellen’s Syndrome: The Life-Threatening Diagnosis. Circulation. 2019 Nov 26;140(22):1851-1852. doi: 10.1161/CIRCULATIONAHA.119.043780. Epub 2019 Nov 25. PMID: 31765255.
3. Rhinehardt J, Brady WJ, Perron AD, Mattu A. Electrocardiographic manifestations of Wellens’ syndrome. Am J Emerg Med. 2002 Nov;20(7):638-43. doi: 10.1053/ajem.2002.34800. PMID: 12442245.
4. Lin AN, Lin S, Gokhroo R, Misra D. Cocaine-induced pseudo-Wellens’ syndrome: a Wellens’ phenocopy. BMJ Case Rep. 2017 Dec 14;2017:bcr2017222835. doi: 10.1136/bcr-2017-222835. PMID: 29246935; PMCID: PMC5753703.
5. Sen A, Fairbairn T, Levy F. Best evidence topic report. Beta-Blockers in cocaine induced acute coronary syndrome. Emerg Med J. 2006 May;23(5):401-2. doi: 10.1136/emj.2006.036582. PMID: 16627850; PMCID: PMC2564096.
6. Nambiar CA, Supreeth RN, Nambiar JH, Reddy MP. Case of Wellens’ Syndrome – A Cautionary Tale. BMH Med. J. 2018;5(4):104-107.