(P04) Wellen's Syndrome: More Than Meets the Eye

Chief Complaint : Chest pain

History of Present Illness : A 38-year-old male with a past medical history of hyperlipidemia presented to the ED with left-sided sharp chest pain with radiation towards the left arm with numbness that began gradually while he was changing the home appliances about 4 hours prior to arrival. He reported shortness of breath, nausea, and one non-bloody non-biliary emesis in the ED, followed by a resolution of chest pain. He denied a previous history of similar pain. No recent fever, chills, cough, traveling, surgery, or lower extremity swelling. No family history of sudden cardiac deaths.

Pertinent Physical Exam: On physical exam, the patient appeared comfortable in his seat and in no acute distress. He was seen helping translate a neighboring patient who only spoke Spanish, as he could speak both languages. Cardiac auscultation with regular rate and rhythm with S1 and S2. No chest wall or rib pain to palpation. Pulmonary auscultation without wheezing, rales, or rhonchi.

Pertinent Laboratory Data: ED vitals: BP 158/95, HR 75, Temperature 98.1 F, RR 17, O2 saturation 98% on room air
ECG#1 (8:21pm): Normal sinus rhythm, rate of 73 bpm, normal axis, normal intervals, with nonspecific ST changes.
Labs (8:31pm): Troponin I 0.97, Creatine kinase 524
Labs (2:40 am): Troponin I 2.99
ECG#2 (2:24am): Normal sinus rhythm, rate of 63 bpm, normal axis, normal intervals, with biphasic T waves in V2-V4 and flattening of T wave in aVL
Labs (6:06am): Troponin I 5.22

Case Discussion: Wellen’s syndrome, also known as anterior descending T-wave syndrome, is defined with an abnormal electrocardiogram pattern: biphasic or deeply inverted T waves in lead V2 and V3.1 Often patients with Wellens are pain-free and with normal or slightly elevated serum markers.2 This patient was a male of relatively young age with hyperlipidemia, which although a known risk factor, would be deemed low suspicion for possible ACS according to validated risk stratification tools, such as the HEART score.3 However, he presented with a moderately concerning chest pain story and was found to have significant troponinemia and dynamic electrocardiogram (ECG) changes over the course of hours while he sat calmly on the chair. At the time of the encounter, the patient was pain-free and with only mild elevation in troponin. It was critical that the repeat ECG was obtained, which demonstrated the dynamic changes suggestive of Type A Wellen’s syndrome, highly concerning for left anterior descending artery occlusion.4 He was subsequently admitted for NSTEMI to the cardiology service.

The following morning, the patient was transferred to the catheterization laboratory and received a left heart catheterization that demonstrated a 100% acute thrombotic occlusion of mid-LAD and 50% stenosis of mid-RCA. During the procedure, he received the intravenous ultrasound-guided percutaneous coronary intervention of the mid-LAD with a 3.0 x 48 Synergy DES. He was discharged home the following day.

References and Acknowledgements (Optional): 1. Miner B, Grigg WS, Hart EH. Wellens Syndrome. [Updated 2022 Aug 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482490/

2. Al-Assaf O, Abdulghani M, Musa A, AlJallaf M. Wellen's Syndrome: The Life-Threatening Diagnosis. Circulation. 2019 Nov 26;140(22):1851-1852. doi: 10.1161/CIRCULATIONAHA.119.043780. Epub 2019 Nov 25. PMID: 31765255.

3. Brady W, de Souza K. The HEART score: A guide to its application in the emergency department. Turk J Emerg Med. 2018 Jun 14;18(2):47-51. doi: 10.1016/j.tjem.2018.04.004. PMID: 29922729; PMCID: PMC6005932.

4. https://litfl.com/wellens-syndrome-ecg-library/\