What is Wellens’ Syndrome?

A 48 year old male presents with a 30 minute episode of central chest pain 12 hours ago. His cardiac enzymes are normal. His ECG looks is below. What do you do next?

wellens syndrome type A

Wellens’ Syndrome.

Essentially it’s an ECG abnormality strongly associated with significant left anterior descending coronary artery stenosis.

There are 2 types of Wellens syndrome:

More detailed criteria for the diagnosis of Wellens’ syndrome:

  • Either of the 2 T wave abnormalities described above.
  • History of chest pain.
  • Normal / minimally elevated cardiac enzymes.
  • No pathological Praecordial Q waves.
  • Minimal / no ST elevation.
  • No loss of praecordial R waves.
Prof Hein J.J. Wellens

Prof Hein J.J. Wellens

First described in 1982 by Professor Hein J. J. Wellens. This syndrome has, along with Brugada Syndrome, become one of the essential instant recognition abnormalities on ECG for Emergency Physicians. The significance of it in a population that could otherwise be sent home from the emergency department is that stress testing as part of your further risk stratification is probably a bad idea. This ECG pattern is strongly associated with a widow maker lesion – with 100% of 180 patients with the pattern having >50% stenosis of the left anterior descending coronary artery (mean = 85%), with complete or near complete occlusion in almost 60%.

Stress testing may prove fatal as there is usually minimal collateral circulation to a large part of the anterior myocardium. Once identified these patients need urgent / emergent angiography and intervention.

Knowledge of Wellens’ Syndrome is becoming so pervasive in some Emergency medicine centres that I’ve frequently heard ECG’s being referred to as ‘Wellenoid’.

References

From the Web:

Journals:

  • de Zwaan C, Bär FW, Janssen JH, Cheriex EC, Dassen WR, Brugada P, Penn OC, Wellens HJ. 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 Mar;117(3):657-65. [PMID: 2784024 ]
  • Zwaan, C de, F W Bär, and H J Wellens. 1982. Characteristic electrocardiographic pattern indicating a critical stenosis high in left anterior descending coronary artery in patients admitted because of impending myocardial infarction. American heart journal, no. 4 Pt 2 [PMID: 6121481]
  • Vanpee D, Courouble P, Marchandise B, Gillet JB.Wellens’ syndrome.Ann Emerg Med. 1999 Nov;34(5):684-5. [PMID: 10533023 ]
  • Hanna, Elias B, and David Luke Glancy. 2011. ST-segment depression and T-wave inversion: classification, differential diagnosis, and caveats. Cleveland Clinic journal of medicine, no. 6. doi:10.3949/ccjm.78a.10077 [PMID: 21632912]
  • Sowers, Nicholas. 2013. Harbinger of infarction: Wellens syndrome electrocardiographic abnormalities in the emergency department. Canadian family physician Médecin de famille canadien, no. 4 [PMID: 23585602]
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