Wellens Syndrome

A 50 year old male presents to the emergency department with an episode of exertional chest pain that occurred 1 hour earlier and has now resolved. He has a history of hypertension and is on amlodipine. Vital signs show blood pressure of 130/80 mm Hg, pulse rate of 88 beats per minute, respiratory rate of 18 breaths per minute, oxygen saturation of 98 percent on room air, and temperature of 96.9 F. ECG shows biphasic T waves in lead V2. Troponin is normal. Diagnosis?

Diagnosis is Type A Wellens syndrome.

1. Definition

Wellens syndrome is an ECG pattern seen in a pain free patient with recent angina, characterized by T wave abnormalities in V2–V3, and is highly suggestive of critical proximal left anterior descending artery stenosis, representing a pre-infarction state.

2. Types

1. Type A Wellens pattern
• Biphasic T waves with initial positivity followed by terminal negativity
• Seen in V2–V3
• Approximately 25 percent of cases
2. Type B Wellens pattern
• Deep, symmetric T wave inversions
• Seen in V2–V3, may extend anteriorly
• Approximately 75 percent of cases

3. Key Diagnostic Features

1. Recent history of anginal chest pain
2. Pain free at time of ECG
3. Characteristic T wave changes in V2–V3
4. Normal or mildly elevated troponin
5. Little or no ST segment elevation
6. No pathologic Q waves

4. Pathophysiology

1. Critical proximal LAD stenosis
2. Transient occlusion followed by spontaneous reperfusion
3. Leads to T wave changes without completed infarction
4. High risk of progression to large anterior myocardial infarction

5. Clinical Significance

1. Represents a pre-infarction state
2. Patient may appear stable and asymptomatic
3. High risk of extensive anterior MI within days if untreated

6. Diagnosis

1. ECG is highly suggestive in the appropriate clinical context
2. Troponin may be normal or mildly elevated
3. Coronary angiography confirms LAD stenosis

7. Management

1. Urgent coronary angiography with revascularization (PCI)
2. Avoid stress testing
3. Initiate acute coronary syndrome therapy
• Antiplatelets
• Anticoagulation
• Statins

8. Key Clinical Insight

Pain free patient with recent angina and biphasic or deeply inverted T waves in V2–V3 with normal troponin strongly suggests Wellens syndrome and requires urgent intervention

9. Exam Level Pearls

1. Wellens syndrome is a pre-infarction LAD lesion
2. Type A shows biphasic T waves, Type B shows deep symmetric inversions
3. Occurs when patient is pain free
4. Troponin may be normal despite critical stenosis
5. Stress testing is contraindicated

 Figure:- ECG showing biphasic T wave in lead V2 suggestive of type A wellens syndrome.