A 57-year-old man presented to the emergency department with 12-hour intermittent retrosternal pain at rest, with cervical and left shoulder irradiation and no precipitating or relief factors. He had history of dyslipidemia and important smoking habits (80 pack/year). His physical examination showed no abnormalities. The electrocardiogram had biphasic T waves in V2 and V3 suggesting a Wellens pattern. Initial high sensitivity troponin I was 257 ng/L (normal range < 16 ng/L) with a maximum peak of 513 ng/L after six hours. The patient underwent coronary angiography that revealed complex 3-vessel coronary disease, with a critical proximal occlusion of the left anterior descending artery. Due to the complexity of the case, an elective angioplasty was scheduled and the patient was admitted in the cardiologic intensive care unit.

Chest pain is one of the most frequent reasons for seeking medical care. The electrocardiogram is an exam often ordered in this context.¹ Wellens syndrome is a pattern of electrocardiographic T-wave changes due to critical proximal stenosis of the left anterior descending artery.² Usually a biphasic (type1) or deep symmetrical inverted (type2) T wave in V2 and V3 may be seen, but occasionally, V1, V4, V5 and V6 may also be affected in type2. Diagnostic criteria of Wellens syndrome include history of angina, little or no cardiac enzymes elevation, minimal or no ST-segment elevation, no pathological Q waves and no loss of precordial R waves.³

Wellens syndrome is rare and indicates an imminent massive anterior infarction, so a timely diagnostic and therapeutic approach are essential.² Urgent cardiac catheterization is vital to prevent myocardial infarction.⁴ Therefore, it is important for the emergency physicians to recognize typical electrocardiographic findings that allow an early intervention.³ This may improve patient’s prognosis and reduce the high morbidity and mortality associated with coronary artery disease.⁵

Figura I

Biphasic T waves in V2 and V3 suggesting a Wellens pattern.

  BIBLIOGRAFIA  

1. Singh D, Suliman I, Chyshkevych I, Dabage N. A Pathognomonic Electrocardiogram That Requires Urgent Percutaneous Intervention : A Case of Wellens Syndrome in a Previously Healthy 55-Year-Old Male. Published online 2019:117-120. doi:10.12659/AJCR.912056

2. Rhinehardt J, Brady WJ, Perron AD, Mattu A. Electrocardiographic manifestations of Wellens’ syndrome. Am J Emerg Med. 2002;20(7):638-643. doi:10.1053/ajem.2002.34800

3. Ozdemir S, Cimilli Ozturk T, Eyinc Y, Onur OE, Keskin M. Wellens’ Syndrome - Report of two cases. Turkish J Emerg Med. 2015;15(4):179-181. doi:10.1016/j.tjem.2014.07.002

4. Ramires TG, Anna JS, Pais J, Picarra BC. Wellens ’ syndrome : a pattern to remember. Published online 2018:1-2. doi:10.1136/bcr-2018-224582

5. Debraj D, Almajed NS. Wellens syndrome. 2016;188(7):8872147. doi:10.1503/cmaj.151209