Wellens Syndrome: A subtle ECG finding
Andrew Chet, DO and Iryna Aleksandrova, MD
Introduction
Wellens syndrome is defined as specific ECG abnormalities
in precordial T-wave segments, which are associated with a
critical stenosis of the left anterior descending artery (LAD).
It was first described in 1982 by de Zwaan1, Wellens and
colleagues who identified a subset of patients who were
admitted to the hospital with symptoms of unstable angina
and either on admission or later on developed characteristic
T-wave changes in precordial leads.
Of patients admitted with unstable angina this syndrome is
seen in 14-18% of cases which makes it a fairly common
finding5. 75% of the patients not operated on developed an
extensive anterior wall myocardial infarction within a few
weeks of admission per original study. Evolution to an
anterior wall MI is rapid, with a mean time of 8.5 days from
the onset of Wellens syndrome to infarction. It is
recommended that patients with this specific subset of
symptoms and ECG findings undergo urgent coronary
angiography and, if possible, coronary revascularization.
Case Presentation
 We present a case of a 76-year-old Caucasian female who
came to the ER with a 2-week history of intermittent upper
retrosternal chest pain, upper back pain and left arm pain.
Chest pain was non-exertional, without specific
precipitating factors, lasted about 5 minutes each time and
resolved spontaneously only to recur again later. She
denied any associated symptoms. The patient however,
reported increasing dyspnea on exertion and bilateral
upper extremity numbness which prompted further
evaluation.
 Her medical history was complicated with cerebral palsy,
hypertension, hyperlipidemia, GERD, chronic low back
pain, and past CVA. She was a former 25 pack/year
smoker, but denied any illicit drug use or alcohol
consumption. On presentation, her vital signs were stable,
physical exam only remarkable for L-sided carotid bruit.
Auscultation of the heart did not reveal any murmurs,
rubs, or gallops. Lungs were clear bilaterally. There were
no lower extremity edema.
 Further workup in the ER revealed an unremarkable CBC,
BMP and lipid panel. Initial cardiac troponins were
indeterminate <0.03, 0.04 and 0.05. Initial ECG revealed T-
wave inversions in V1-V3 and deep T waves in V4-5
without any ST segment changes. Patient was
administered aspirin, nitroglycerin, morphine and admitted
to the hospital.
 A Lexiscan Myoview stress test was ordered and revealed
an anteroseptal fixed defect with some mild apical septal
reversibility with an estimated ejection fraction of 65%.
Apical and inferolateral hypokinesis were also noted.
 In light of her worsening symptoms, the decision was
made to undergo cardiac catheterization which
serendipitously found a 95% tubular stenosis in the
proximal LAD. CABG was recommended and the patient
underwent successful coronary artery bypass grafting with
left internal mammary artery x 2. Postoperative, her
clinical course was complicated with atrial fibrillation with
RVR and prolonged pauses in cardiac activity which
eventually prompted insertion of a pacemaker.
Swedish Covenant Hospital, Chicago, Illinois
ECG
Biphasic and Deep T Wave Inversions
NM Myoview PCI
Anteroseptal Fixed Defect LAD Critical Stenosis
Acknowledgements
We would like to thank the Swedish
Covenant Hospital faculty and staff for
their collaboration in this patient case.
Special consideration to Walter Baba MD,
PHD and Steve Attanasio, DO for their
contribution and case review in
preparation of this poster.
Discussion
Wellens syndrome also known as LAD coronary T wave
syndrome is a critical stenosis of the proximal left anterior
descending (LAD) coronary artery.
Typical cases present as either Type I: biphasic T waves or
Type II: deeply inverted T waves in the precordial leads.
Wellens Syndrome Criteria2
 Prior history of chest pain
 During chest pain ECG normal or with mild ST elevation or
depression, or with terminal negative deflection of T wave
in V1/V2
 Cardiac enzymes are normal or mildly elevated
 No pathologic precordial Q waves
 No loss of precordial R waves
 Deeply inverted or biphasic T waves in V2/V3, possibly
V1/V4/V5/V6 when pain free
Patients with suspected Wellens Syndrome should undergo
immediate cardiac catheterization. Stress testing is
contraindicated in this syndrome as increasing cardiac
demands with a highly stenosed LAD may evoke a
myocardial infarction3.
It is evident that the patient in the case has a Wellens
variant4 of biphasic T waves in V2-V3, and deeply inverted T
waves in V4-V5. However, due to the arguably discreet and
clandestine presentation, the patient underwent stress
testing and further workup prior to cardiac catheterization.
Our patient represents a very fortuitous and rare case of
Wellens Syndrome as the time frame from door of the ER to
the cardiac cath lab was approaching the mean time to
infarction of 8.5 days1.
 Wellens Syndrome is a medical zebra that is not familiar to
many physicians. The relatively subtle ECG findings with no
to little cardiac enzyme elevation mask a potentially
dangerous and life-threatening syndrome.
As clinicians, it is of paramount importance to recognize
this syndrome because it represents a preinfarction stage of
coronary artery disease (CAD) that often progresses to
extensive anterior wall MI and severe left ventricular
dysfunction. We must be able to identify simple, yet easy-to-
miss ECG changes.
References
1. de Zwaan C, Bar 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. Apr 1982; 103 (4 Pt 2): 730-6.
2. Mead N, O’ Keefe K. Wellens Syndrome: An ominous EKG
pattern. J Emerg Trauma Shock. 2009 Sep-Dec; 2(3):206-8.
3. Tatli E, Aktoz M, Buyuklu M, Altun A. Wellens' syndrome:
the electrocardiographic finding that is seen as unimportant.
Cardiol J. 2009;16(1):73-5.
4. Narasimhan S, Robinson GM. Wellens syndrome: a
combined variant. J Postgrad Med. Jan-Mar 2004;50(1):73-4.
5. de Zwaan 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. Mar
1989;117(3):657-65.