Clinical Review & Education

Challenges in Clinical Electrocardiography

A Nearly Stressful Situation—a Case of Wellens Syndrome

Daniel Yazdi, MD, MSc; Justin Sharim, MD

A man in his 70s with no history of cardiovascular disease presented
to the emergency department after a single episode of chest pres-
sure the previous day. He noted substernal pressure that resolved
after 10 minutes of rest but did not complain of any other symp-
toms. He presented to the emergency department 1 day later at the
recommendation of his primary care provider. He had not experi-
enced any chest pressure since the single episode.
On presentation, the patient was hemodynamically stable with
a blood pressure of 153/69 mm Hg and heart rate of 63 beats per
minute; he was breathing comfortably on room air. His cardiac ex-
amination was normal without any murmurs or gallops. His neck
veins were nondistended, and breath sounds were normal. Results
of his blood chemistry tests and complete blood count were within
normal limits. His troponin T hs Gen 5 was 0.32 ng/L (reference range,
0-14 ng/L) with a repeat measurement of 0.30 ng/L 1 hour later.
An electrocardiogram (ECG) was performed (Figure 1A).
Because the patient was clinically stable without anginal
symptoms and with decreasing serum troponin levels, he was ad-
mitted to the observation unit for an expedited cardiac stress test.
Questions: What are the ECG findings? How would this adjust
your management?
Interpretation
The ECG demonstrates normal sinus rhythm and a regular rate.
It is notable for T-wave inversions most prominent in leads V1
through V3 and a biphasic T wave in lead V4. There appears to be a
conduction delay in lead V1 and nonpathologic Q waves (<0.03
seconds wide and 0.1 mV in amplitude). These ECG findings in
combination with the patient’s history of resolved chest pressure
was concerning for impending proximal left anterior descending
coronary artery (LADCA) occlusion, a finding termed Wellens syn-
drome.

Figure 1. Electrocardiographic Results at Presentation and Resolution

A Electrocardiographic findings at presentation

B Electrocardiographic findings at 6-month follow-up

A, Inverted T waves are seen in leads

V2 and V3, and a biphasic T wave is
present in lead V4 (arrowheads),
which is indicative of Wellens
syndrome. The inverted T wave
in lead V1 can be a normal variant.
B, These findings were obtained after
the placement of the drug-eluting
stent. The arrowheads show
resolution of the T-wave inversions.

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 Clinical Review & Education Challenges in Clinical Electrocardiography
Figure 2. Coronary Angiographic Results at Presentation and Resolution
A Occlusion of LADCA B Resolution of occlusion
Clinical Course
Owing to concern for LADCA occlusion despite lack of symptoms and
downtrending cardiac enzymes, the patient was treated for acute
coronary syndrome using aspirin, clopidogrel, metoprolol, high-
dose atorvastatin, and therapeutic heparin drip. Prior to a left heart
catheterization, a transthoracic echocardiogram showed a normal
left ventricular ejection fraction with focal hypokinesis of the infero-
apical and apical left ventricular walls. Rather than subjecting the pa-
tient to a cardiac stress test (as originally considered), he under-
went coronary angiography, which demonstrated 100% occlusion
of the mid LADCA (Figure 2A); proximal to the occlusion, the LADCA
was aneurysmal. There were collaterals to the distal LADCA from the
right coronary artery. The lesion was successfully dilated, and a drug-
eluting stent was placed, which resulted in reduction of the occlu-
sion from 100% to 0% (Figure 2B). The patient did well and was dis-
charged the following day on treatment with atorvastatin, aspirin,
clopidogrel, metoprolol, and lisinopril, and a scheduled cardiology
outpatient follow-up. His ECG during his outpatient appointment 6
months later showed resolution of the T-wave inversions (Figure 1B).
Discussion
Diagnosing Wellens syndrome can be challenging and requires a high
index of suspicion. The criteria for Wellens syndrome includes: (1)
deeply inverted or biphasic (initially positive followed by negative
deflections from baseline) T waves in leads V2 through V3 with in-
verted T waves occasionally seen in the remaining precordial leads,
(2) the presence of these ECG findings when the patient is free of
chest pain, (3) no signs of acute anterior wall myocardial infarction
(ST-segment elevation, >1 mm), (4) no precordial Q waves or loss of
R waves, (5) a recent history of angina pectoris, and (6) normal to
slightly elevated cardiac markers.1
Hein Wellens initially noted this ECG pattern in 1982 when 26 of
145 patients admitted to the hospital with unstable angina were found
to have these characteristic changes.2 Of the 16 patients who did not
undergo bypass surgery, 12 patients later developed significant ante-
rior wall myocardial infarction within a mean of 8.5 days. Another study
later found the positive predictive value of Wellens syndrome for de-
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A, Arrowhead points to the 100%
occlusion of the mid left anterior
descending coronary artery (LADCA).
B, The same region after the
placement of a drug-eluting stent and
resolution of the occlusion to 0%.
tecting significant LADCA stenosis to be 86%.3 T-wave inversions as-
sociated with Wellens syndrome are not a sign of acute LADCA occlu-
sion, but rather LADCA reperfusion hours to days after myocardial is-
chemia subsides.4 A rare physical examination finding in patients with
suspected Wellens syndrome is an early diastolic murmur in the third
intercostal space at the midclavicular line caused by diastolic flow tur-
bulenceintheLADCA,referredtoasDock’smurmur.5 Thismurmurwas
not audible in the present patient.
T-wave inversions in and of themselves do not equate to Wellens
syndrome. The differential diagnosis for precordial T-wave inversions
is broad and includes left ventricular hypertrophy, pulmonary embo-
lism, cerebral hemorrhage, cocaine-induced coronary vasospasm,
chronic thromboembolic pulmonary hypertension, and Takotsubo
cardiomyopathy.6,7 A thorough history and physical examination are
needed to narrow the differential. If Wellens syndrome is suspected,
revascularization should be attempted with curative intent. Failure to
catheterize the LADCA is associated with a high probability of subse-
quent significant anterior myocardial wall injury.
In general, cardiac stress tests should not be performed in pa-
tients with unstable cardiac abnormalities. However, in Wellens syn-
drome these warning signs are absent and patients are often re-
ferred for stress testing, as was the situation in this case report.
Because Wellens syndrome is a predictor of critical LADCA steno-
sis, cardiac stress testing is not recommended and may in fact be
harmful by increasing myocardial oxygen demand.8 With early rec-
ognition of Wellens syndrome, initiation of acute coronary syn-
drome treatment, and definitive revascularization, significant mor-
bidity and mortality can be avoided.
Take-Home Points
• Recognize the ECG pattern of Wellens syndrome.
• Be familiar with the differential diagnosis for precordial T-wave
inversions.
• If there is sufficient concern for Wellens syndrome, a cardiac stress
test is not recommended.
• Revascularization should be pursued for definitive management.
jamainternalmedicine.com

Author Affiliations: Brigham and Women’s
Hospital, Boston, Massachusetts (Yazdi); UC
San Diego Medical Center, San Diego, California
(Sharim).
Corresponding Author: Daniel Yazdi, MD, MSc,
Brigham and Women’s Hospital, 75 Francis St,
Boston, MA 02115 (dyazdi@bwh.harvard.edu).
ARTICLE INFORMATION
Published Online: March 18, 2019.
doi:10.1001/jamainternmed.2019.0216
Conflict of Interest Disclosures: None reported.
Additional Contributions: We would like to thank
Joseph Loscalzo, MD, PhD, of the Department of
Medicine at Brigham and Women’s Hospital for
providing guidance as well as reviewing and editing
this article.
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Challenges in Clinical Electrocardiography Clinical Review & Education
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