Wellens Syndrome Important to Consider in Chest Pain: Key Points

Alexander J, Rizzolo D.
Wellens Syndrome: An Important Consideration in Patients With Chest Pain. JAAPA 2023;Jan 9:[Epub ahead of print].

The following are key points to remember from this article about Wellens syndrome, an important consideration in patients with chest pain:

  1. Wellens syndrome is a form of acute coronary syndrome (ACS) associated with critical disease of the left anterior descending (LAD) coronary artery. It is associated with characteristic electrocardiography (ECG) patterns.
  2. The ECG may appear normal during an episode of chest discomfort in a patient with Wellens syndrome. Conversely, classic ECG abnormalities associated with Wellens syndrome may be subsequently observed when the patient is pain-free. Clinicians should obtain serial ECGs, including after pain resolution, to detect the syndrome.
  3. There are two classic ECG patterns observed with Wellens syndrome. Type A (less common) is associated with biphasic T waves in leads V2 and V3, whereas type B (more common) is associated with deep T-wave inversions in leads V2 and V3. Similar ECG changes may occur in any of the precordial (V1–V6) leads.
  4. ECG criteria for Wellens syndrome also include isoelectric or minimally elevated (<1 mm) ST-segment elevation or ST-segment depression and exclude pathologic Q waves, left or right bundle branch block, left or right ventricular hypertrophy, and poor R-wave progression.
  5. Wellens ECG patterns have a high degree of specificity for LAD occlusion—99% specificity for type A and 97% specificity for type B.
  6. Careful evaluation of the patient’s clinical presentation is imperative due to the broad differential diagnosis—including noncardiac causes—of chest pain and/or inverted T waves.
  7. Diagnostic workup of Wellens syndrome should include a focused history and physical exam with assessment of cardiovascular risk factors and use of illicit substances, especially cocaine, troponin levels, and chest imaging. Lab studies should also include complete blood cell count, comprehensive metabolic profile, B-type natriuretic peptide, and coagulation panel. D-dimer should be obtained if pulmonary embolus is suspected.
  8. Imaging study with echocardiogram may reveal diminished left ventricular function or left ventricular wall motion abnormalities. Coronary computed tomography angiography may reveal coronary artery occlusion or stenosis. Cardiac stress testing should be avoided in these patients because stress testing may precipitate myocardial infarction (MI), arrhythmia, or death.
  9. Patients with Wellens syndrome require hospital admission and urgent cardiology consultation. Definitive treatment of Wellens syndrome involves early coronary intervention with coronary stent to the LAD or coronary artery bypass graft surgery.
  10. In the absence of coronary intervention or bypass, most patients with Wellens syndrome will develop anterior MI.

Clinical Topics: Acute Coronary Syndromes, Arrhythmias and Clinical EP, Cardiac Surgery, Cardiovascular Care Team, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Vascular Medicine, ACS and Cardiac Biomarkers, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Aortic Surgery, Cardiac Surgery and Arrhythmias, Interventions and ACS, Interventions and Imaging, Interventions and Vascular Medicine, Angiography, Computed Tomography, Echocardiography/Ultrasound, Nuclear Imaging

Keywords: Acute Coronary Syndrome, Angiography, Arrhythmias, Cardiac, Chest Pain, Computed Tomography Angiography, Coronary Artery Bypass, Coronary Occlusion, Diagnostic Imaging, Echocardiography, Electrocardiography, Myocardial Infarction, Myocardial Ischemia, Natriuretic Peptide, Brain, Patient Care Team, Percutaneous Coronary Intervention, Pulmonary Embolism, Risk Factors, Stents, Troponin

< Back to Listings