A 66-year-old woman is referred to you for clearance to undergo hernia surgery. In the office, during her review of systems, she mentions that she occasionally gets 5 to 10 minutes of epigastric pain after meals, which is always relieved by taking Pepto-Bismol. She denies any chest pain, trouble breathing, or other symptoms during these episodes, and she currently has no pain. She thinks the last time she had it was 3 or 4 days ago.
The patient’s physical examination is essentially unremarkable except for mild obesity. Specifically, her vital signs are all normal, her lungs are clear, and her heart is regular, without any abnormal heart sounds. She has no abdominal tenderness or mass. Her legs are free of edema.
Below are the precordial lead tracings of her ECG taken while she is pain-free in your office. You have no old ECG available for comparison. Labs, including a complete blood cell count, metabolic panel, and cardiac enzymes, are all normal, except for a glucose level of 132 mg/dL.
Can this patient be cleared for surgery or should she have a stress test first?
Answer: Neither! (This is a trick question)
The patient needs a cardiac cath. Her epigastric pain is likely an anginal equivalent provoked by meals shunting blood to her GI system and away from her heart. Her ECG shows a finding known as Wellens warning, or Wellens syndrome, which is explained below.
In 1982, Hein Wellens described certain ECG findings that are specific for high-grade stenosis of the proximal left anterior descending (LAD) coronary artery.1 Two distinct patterns of ECG changes were described:
Type 1: Biphasic T waves in leads V2 and V3. This form accounts for about 25% of cases but is important to be aware of because ECG changes may be subtle and are often missed by the computer or read by the computer as “nonspecific T-wave changes.” Leads V1 and V4 are also commonly affected.
Type 2: Deep T-wave inversions in leads V2 through V4. This form accounts for about 75% of cases. ECG findings for type 2 are more pronounced and usually read by the computer as suggestive of ischemia. Interestingly, T-wave inversions in the anterior leads can also be associated with submassive pulmonary embolism, which may be painless and present only with dyspnea or dyspnea on exertion.
Wellens syndrome includes 1 of these 2 ECG findings along with the following criteria:
• Isoelectric or minimal ST-segment elevation (<1 mm).
• No precordial Q waves.
• History of angina or angina equivalent.
• Patient pain-free when ECG pattern noted.
• Normal or minimally elevated cardiac serum markers.
In Wellens’ second study,2 all of the patients admitted with this syndrome had greater than 50% stenosis of the proximal LAD and more than 50% had greater than 85% stenosis.
The importance of recognizing Wellens syndrome cannot be overemphasized. The literature shows case reports of patients with a history of anginal-type pain who met all of the Wellens criteria but mistakenly were deemed safe to stress test and then went on to develop large anterior wall myocardial infarctions (MIs) during exercise. Characteristic ECG changes in the setting of Wellens syndrome are a serious warning in an otherwise asymptomatic patient.
Management should include aspirin and, if not contraindicated, heparin and proceeding directly to cardiac angiography. If this warning is missed, the patient may be destined for an otherwise preventable large anterior wall MI, or death, or both.
|Wellens Syndrome: The Quick Essentials from Quick Essentials Emergency Medicine pocketbook|
|Symptoms||Biphasic or deep T waves in V2 through V3 usually seen while patient is pain-free. Changes look nonspecific but signify severe proximal LAD (left anterior descending) stenosis.|
|Rx|| Do not do a stress test because it is too risky. Go straight to cath instead. |
1. de Zwann C, Bar FW, Wellens HJJ. 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.
2. de Zwann C, Bar FW, Janssen JH, et al. Angiographic and clinical characteristics of patients with unstable angina showing an ECG pattern indicating critical narrowing of the proximal LAD coronary artery. Am Heart J. 1989;117:657-665.
3. Tandy TK, Bottomy DP, Lewis JG. Wellens' syndrome. Ann Emerg Med. 1999;33:347-351.
4. Rhinehardt J, Brady WJ, Perron AD, Mattu A. Electrocardiographic manifestation of Wellens' syndrome. Am J Emerg Med. 2002;20:638-643.