Wellens Syndrome: ECG

Wellens Syndrome: ECG Recognition and Immediate Management

Clinical significance

• Wellens syndrome is a high-risk electrocardiographic pattern that occurs during a pain-free interval and indicates critical proximal left anterior descending (LAD) coronary stenosis.[1-3]
• It identifies patients at risk of an impending, extensive anterior myocardial infarction (MI).[1-3]
• The pattern is associated with transient ischemia from plaque rupture and spontaneous reperfusion rather than ongoing complete LAD occlusion.[1,3]

Required clinical context

• Recent angina or chest pain.
• ECG obtained while the patient is pain-free.[1,3,5]
• Cardiac biomarkers that are normal or only mildly elevated.[1,5]

Core ECG criteria

• Precordial T-wave abnormalities, most often in V2-V3, with possible extension from V1 through V6.[1,2,5]
• Isoelectric or minimally elevated ST segments.[1,5]
• No pathologic precordial Q waves or loss of R-wave progression.[1,5]
• No anterior ST-segment elevation greater than 1 mm suggesting acute anterior MI.[5]

T-wave patterns

• Type A: Biphasic T waves, with an initial positive deflection followed by a negative deflection.
  • Usually occurs in V2-V3.
  • May extend from V1 through V6.
  • Reported in approximately 24% to 30% of cases.[1,4,5]
• Type B: Deep, symmetric T-wave inversions.
  • Usually occurs in V2-V3.
  • May extend to V1 and V4-V6.
  • Reported in approximately 70% to 76% of cases.[1,4]

Relationship to de Winter pattern

• A Wellens pattern may evolve directly from a de Winter ECG pattern.[6]
• This evolution may reflect partial LAD recanalization.[6]

Emergency management

• Treat the pattern as a high-risk acute coronary syndrome, even if the patient is currently pain-free and troponin is normal.[2,3,6]
• Obtain urgent cardiology involvement.
• Pursue early coronary angiography.
• Avoid stress testing because it can be unsafe in the setting of critical proximal LAD disease.[2,3,6]

Summary takeaway

• Recognize Wellens syndrome from its characteristic pain-free precordial T-wave abnormalities in a patient with recent ischemic chest pain.
• Do not be reassured by symptom resolution, absence of ST elevation, or minimally elevated biomarkers.
• Escalate promptly for cardiology evaluation and early angiography rather than stress testing.

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References

1. Plappert C, Sherif M, Oeing C. Intermittent Chest Pain in a 46-Year-Old Patient. JAMA. 2022;328(20):2058-2059. doi:10.1001/jama.2022.19443.
2. Kontos MC, de Lemos JA, Deitelzweig SB, et al. 2022 ACC Expert Consensus Decision Pathway on the Evaluation and Disposition of Acute Chest Pain in the Emergency Department. Journal of the American College of Cardiology. 2022;80(20):1925-1960. doi:10.1016/j.jacc.2022.08.750.
3. Honda S, Kawasaki T. Wellens' Syndrome. New England Journal of Medicine. 2022;387(12):e25. doi:10.1056/NEJMicm2201699.
4. Xenogiannis I, Vemmou E, Sharkey SW. Serial T-Wave Changes in a Patient With Chest Pain. JAMA Internal Medicine. 2022;182(8):874-875. doi:10.1001/jamainternmed.2022.2389.
5. Yazdi D, Sharim J. A Nearly Stressful Situation: A Case of Wellens Syndrome. JAMA Internal Medicine. 2019;179(5):704-706. doi:10.1001/jamainternmed.2019.0216.
6. Zhu Y, Luo S, Huang B. Evolution of de Winter Into Wellens on Electrocardiogram: What Happened? JAMA Internal Medicine. 2021;181(12):1647-1649. doi:10.1001/jamainternmed.2021.5734.

Clinical decisions should use local protocols and specialist consultation.