Wellen's Syndrome

Aka: Wellen's Syndrome, Wellens Syndrome, Left Anterior Descending Coronary T Wave Syndrome, LAD Coronary T Wave Syndrome, Wellens Waves

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II. History

  1. First described by Dutch cardiologist Hein Wellens in 1982 article, predicting LAD event in 75% of patients with criteria

III. Criteria: Wellens Syndrome (LAD Coronary T Wave Syndrome)

  1. Anterior T Waves abnormality in leads V2 and V3 (may involve all precordial leads)
    1. Type A: Biphasic T Waves, initially positive and then negative (25% of cases, early finding)
    2. Type B: Deep T Wave Inversion (75% of cases, later finding)
  2. ST Segment normal (or <1 mm of ST Elevation)
  3. No precordial Q Waves AND Preserved Precordial R Wave Progression
  4. Cardiac enzymes (e.g. serum Troponin) normal or minimally elevated
  5. Associated with recent Angina, but EKG performed when pain free
    1. Known as "Wellens Waves" when patients are symptomatic (e.g. Chest Pain) with ongoing cardiac ischemia

IV. Differential Diagnosis: Pseudo-Wellens (Repolarization Abnormalities)

  1. See T Wave
  2. Pulmonary Embolism
  3. Right Bundle Branch Block
  4. Left Bundle Branch Block
  5. Left Ventricular Hypertrophy
  6. Hypertrophic Cardiomyopathy
  7. Normal variant (e.g. children)
  8. Brugada Syndrome
  9. Hypokalemia
  10. Intracranial Hemorrhage

V. Interpretation

  1. Wellens Syndrome suggests critical left anterior descending artery ischemia
    1. T Wave abnormalities represent reperfusion after ischemic event
    2. Although patients are pain free, the Wellens related EKG changes typically persist until revascularization (e.g. PTCA)
  2. High risk for significant anterior wall Myocardial Infarction in the coming days to weeks (regardless of symptoms)
    1. Wellens Syndrome in the appropriate context is an indication for admission and urgent cardiac catheterization
    2. Avoid provocative cardiac stress testing in patients with Wellens Syndrome related findings
    3. Urgent PCI may be indicated (next day), but emergent PCI (STEMI Equivalent) is not indicated
      1. Wellens is also not an indication for Thrombolytics when PCI is not immediately available

VI. Resources

  1. Wellen's Syndrome (Life in the FastLane)
    1. http://lifeinthefastlane.com/ecg-library/wellens-syndrome/

VII. References

  1. Berbarian, Brady and Mattu (2023) Crit Dec Emerg Med 37(2): 12-3
  2. Weingart and Swaminathan (2023) EM:Rap, accessed 10/1/2023
  3. Rhinehart (2002) Am J Emerg Med 20(7):638-43 +PMID:12442245 [PubMed]
  4. Tatli (2009) Cardiol J 16(1):73-5 +PMID:19130419 [PubMed]
  5. de Zwaan (1982) Am Heart J 103(4 Pt 2):730-6 +PMID: 6121481 [PubMed]

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