Case of the month: Don’t defer intervention.  Delays have dangerous ends: Wellens  syndrome   Revisited
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Case of the month: Don’t defer intervention. Delays have dangerous ends: Wellens syndrome Revisited

Contributed by 

Dr Parey Mohd Farooq . MD,MRCEM

Emergency medicine Specialist ,University Hospital of Morecambe bay

NHS foundation trust ,United Kingdom


Clinical Scenario 

A 63 year old male woke up with substernal chest pain 8/10 ,radiating to left arm associated with mild sweating. The pain lasted for 10 minutes and resolved spontaneously .After an hour ,while walking briskly in the lawn ,he had another episode of Retrosternal Chest pain which was more intense with profuse sweating .EMS  were called upon ,arrived within 30 minutes, managed him with Nitroglycerine puffs and Aspirin after which his pain resolved completely

 Past medical History Dyslipidemia ,non-compliant  to treatment 

Heavy smoker -2 packets a day for 15 years 

Lives alone ,very fit  , tend to exercise regularly 

No previous surgical interventions ,No allergies 

Drinks occasionally ,denies illicit drug abuse 

Clinical Course On arrival to the Emergency department he was clinically asymptomatic .He was hemodynamically stable and denied any Chest pain or Shortness of breath . His was conscious, orientated .His respiratory and cardiovascular exam was unremarkable .He had no lower limb edema A 12 lead ECG  was obtained immediately on arrival Fig 1 

Fig 1 ECG on Arrival 

ECG  interpretation:;Normal Sinus rhythm , Normal axis  Biphasic  T waves in precordial leads ,prominent in V2-V4 with terminal  negativity  . 

 Subtle  STE  V3-V4   ,preserved r wave progression , Normal qrs 

Initial Troponin = 45 ng/l  Normal range <20 ng/l 

WBC =6.7  Hb=146 ,Platelets =206 , Na=137,K=4,5

X Ray chest-normal lung fields ,normal cardiac silhouette 

Bedside echo : No regional wall motion abnormality

Hospital course 

With the clinical impression of Wellens syndrome  cardiology referral was done  &  recommendation of early cardiac catheterisation was  discussed accordingly   As per cardiology recommendations he was admitted as Acute coronary syndrome under NSTEMI pathway .

It was decided that due to absence of active chest pain ,he wouldn’t be a candidate for emergent cardiac catheterisation  .

Treatment with Aspirin ,clopidogrel & Fondaparinux was initiated accordingly .Telemetry was requested and  he remained  stable and asymptomatic .

 Two  hours later while awaiting for a bed in CCU  patient developed intense substernal chest pain  10/10 radiating to both shoulders .

He was feeling short of breath and sweating  profusely .He was immediately shifted to the resus room ,attached to cardiac monitor  & pads were placed accordingly . 

His blood pressure was  178/98 ,hr=76 ,  Spo2 was 97 % from air  . 

A 12 lead ECG  was obtained .Fig2 below



Fig 2 ECG 2hrs later 

Anteroseptal Myocardial infarction with St elevation in  V1-V4  with  inferior reciprocal depression ….

STEMI pathway was activated and patient was immediately transferred  for cardiac catheterisation . Coronary angio revealed 95% stenosis of proximal LAD which was successfully treated with drug eluted stent accordingly .He was discharged in good condition and is currently doing well

Teaching message in the case 

Wellens syndrome is a specific ECG  pattern associated with clinical  signs .It’s not a just an ECG  findings 

The Diagnostic criteria for Wellens syndrome are  1. history of cardiac chest pain, 2.biphasic T waves  in V2-V3 (extending to V5-V6) with terminal negativity        and/ or 3.deep T wave inversions, with preserved  R wave progression in precordial leads   and normal to minimally elevated Troponin 

There are two  different types of  T wave patterns and they are seen with complete resolution of pain

-Its   considered a  warning sign and signifies critical proximal LAD occlusion 

-Early cardiac catheterisation is indicated to improve mortality and morbidity 

-Its mostly seen in anterior leads however similar pattern has been described in inferior and lateral leads

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