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Wellens Syndrome Treatment & Management

  • Author: Benjamin B Mattingly, MD; Chief Editor: Erik D Schraga, MD  more...
 
Updated: Jan 02, 2015
 

Approach Considerations

A cardiologist should be consulted early in the management of a patient with Wellens syndrome. If the patient remains pain-free, it is appropriate to admit him or her to an internist on a telemetry floor, but the internist should be notified that the patient is at high risk and should not undergo stress testing.

If symptoms persist or electrocardiography (ECG) shows evolution into ST-segment elevations, an interventional cardiologist should be consulted immediately. Transfer of these patients to institutions with cardiac catheterization capabilities is generally appropriate.

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Prehospital Care

Because Wellens syndrome occurs because of stenosis of the left anterior descending (LAD) coronary artery, patients typically complain of chest pain presenting as unstable angina. During episodes of pain, they should be treated in the same manner as any patient experiencing chest pain thought to be cardiac in origin.

Immediate arrangements should be made for transport to the nearest hospital. Careful attention should be paid to the ABCs (airway, breathing, and circulation). During transport, efforts should be made to carry out the following:

  • Oxygen supplementation
  • Assessment of vital signs
  • Intravenous (IV) access
  • Administration of aspirin
  • ECG, if available before arrival at the hospital
  • If pain persists, administration of nitroglycerin or morphine, according to local protocols

If Wellens syndrome is identified on an outpatient basis, then arrangements should be made for urgent evaluation. Stress testing should be avoided.

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Emergency Stabilization, MI Prevention, and Pharmacotherapy

Patients presenting with symptoms consistent with unstable angina should generally receive medications and other therapies and measures that may help prevent myocardial infarction (MI). Usually, these would include the following:

  • IV access
  • Supplemental oxygen
  • ECG (initially) – Serial examinations and pain-free tracings may be helpful
  • Telemetry monitoring
  • Chest radiography
  • Laboratory studies (see Laboratory Studies)
  • Consideration should be given to providing aspirin, beta-blocker therapy, nitroglycerin, morphine, heparin, clopidogrel, and glycoprotein (GP) IIb/IIa inhibitors

Once again, the ECG changes in Wellens syndrome are typically only present when the patient is free of chest pain. Thus, obtaining serial ECGs on patients with unstable angina may be helpful.

Even though the ECG changes may be subtle, it is vital to recognize Wellens syndrome because these patients can rarely undergo stress testing safely.[10, 11, 12] Because Wellens syndrome is a sign of a preinfarction stenosis of the LAD, a stress test has the potential to result in acute MI and severe damage to the left ventricle. Therefore, these patients should generally forgo a stress test and instead may undergo angiography to evaluate the need for angioplasty or coronary artery bypass surgery (CABG).

Even with ideal medical management, the natural progression of Wellens syndrome is to acute anterior wall MI. Approximately 75% of patients with Wellens syndrome who receive only medical management and do not undergo revascularization (either through CABG or through angioplasty) will go on to develop extensive anterior wall MI within days.[13, 1] Anterior wall MI carries substantial morbidity and mortality: it will result in left ventricular dysfunction and possibly even death.

Thus, patients generally should be medically stabilized if possible while arrangements are made for urgent angiography and revascularization if appropriate.

Further inpatient care for patients with Wellens syndrome includes the following:

  • Attempts to keep the patient pain-free
  • Provision of a telemetry bed to monitor the patient.
  • Consultation with a cardiologist
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Contributor Information and Disclosures
Author

Benjamin B Mattingly, MD Assistant Professor, Department of Emergency Medicine, Tufts University School of Medicine, Baystate Medical Center

Benjamin B Mattingly, MD is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Kevin M Gentile, DO Attending Physician, Department of Emergency Medicine, MEP at Bristol Hospital

Kevin M Gentile, DO is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Osteopathic Association, Massachusetts Medical Society, Emergency Medicine Residents' Association

Disclosure: Nothing to disclose.

Chief Editor

Erik D Schraga, MD Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

Acknowledgements

Edward Bessman, MD Chairman, Department of Emergency Medicine, John Hopkins Bayview Medical Center; Assistant Professor, Department of Emergency Medicine, Johns Hopkins University School of Medicine

Edward Bessman, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Gary Setnik, MD Chair, Department of Emergency Medicine, Mount Auburn Hospital; Assistant Professor, Division of Emergency Medicine, Harvard Medical School

Gary Setnik, MD is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians, and Society for Academic Emergency Medicine

Disclosure: SironaHealth Salary Management position; South Middlesex EMS Consortium Salary Management position; ProceduresConsult.com Royalty Other

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

References
  1. de Zwaan C, Bar FW, Wellens HJ. Characteristic electrocardiographic pattern indicating a critical stenosis high in left anterior descending coronary artery in patients admitted because of impending myocardial infarction. Am Heart J. 1982 Apr. 103(4 Pt 2):730-6. [Medline].

  2. Nisbet BC, Zlupko G. Repeat Wellens' Syndrome: Case Report of Critical Proximal Left Anterior Descending Artery Restenosis. J Emerg Med. 2008 Apr 2. [Medline].

  3. Patel K, Alattar F, Koneru J, Shamoon F. ST-Elevation Myocardial Infarction after Pharmacologic Persantine Stress Test in a Patient with Wellens' Syndrome. Case Rep Emerg Med. 2014. 2014:530451. [Medline]. [Full Text].

  4. Moore KL, Dalley AF. Thorax. Clinically Oriented Anatomy. 4th ed. Baltimore, Maryland: Lippincott Williams & Wilkins; 1999. 135.

  5. de Zwaan C, Bar FW, Janssen JH, et al. Angiographic and clinical characteristics of patients with unstable angina showing an ECG pattern indicating critical narrowing of the proximal LAD coronary artery. Am Heart J. 1989 Mar. 117(3):657-65. [Medline].

  6. Tandy TK, Bottomy DP, Lewis JG. Wellens' syndrome. Ann Emerg Med. 1999 Mar. 33(3):347-51. [Medline].

  7. Rhinehardt J, Brady WJ, Perron AD, Mattu A. Electrocardiographic manifestations of Wellens' syndrome. Am J Emerg Med. 2002 Nov. 20(7):638-43. [Medline].

  8. Tatli E, Aktoz M, Buyuklu M, Altun A. Wellens' syndrome: the electrocardiographic finding that is seen as unimportant. Cardiol J. 2009. 16(1):73-5. [Medline].

  9. Narasimhan S, Robinson GM. Wellens syndrome: a combined variant. J Postgrad Med. 2004 Jan-Mar. 50(1):73-4. [Medline].

  10. Sowers N. Harbinger of infarction: Wellens syndrome electrocardiographic abnormalities in the emergency department. Can Fam Physician. 2013 Apr. 59(4):365-6. [Medline]. [Full Text].

  11. Balasubramanian K, Balasubramanian R, Subramanian A. A dangerous twist of the 'T' wave: A case of Wellens' Syndrome. Australas Med J. 2013. 6(3):122-5. [Medline]. [Full Text].

  12. Singh B, Singh Y, Singla V, Nanjappa MC. Wellens' syndrome: a classical electrocardiographic sign of impending myocardial infarction. BMJ Case Rep. 2013 Feb 18. 2013:[Medline].

  13. Movahed MR. Wellens' syndrome or inverted U-waves?. Clin Cardiol. 2008 Mar. 31(3):133-4. [Medline].

 
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This ECG represents a patient who came in to the emergency department with 8/10 chest pain. The patient had old right bundle-branch block (RBBB) and left ventricular hypertrophy (LVH), and this compared similarly to his previous ECGs.
Classic Wellens syndrome T-wave changes. ECG was repeated on a patient who came in to the emergency department with 8/10 chest pain after becoming pain free secondary to medications. Notice the deep T waves in V3-V5 and slight biphasic T wave in V6 in this chest pain– free ECG. The patient had negative cardiac enzyme levels and later had a stent placed in the proximal left anterior descending (LAD) artery.
A 57-year-old with 4/10 pressurelike chest pain. Improvement with treatment by EMS. The patient had this ECG on arrival. Notice perhaps the beginning of a small biphasic T wave in V2.
Pain-free ECG of a 57-year-old patient who presented with 4/10 pressurelike chest pain. Notice after the patient was treated with medications and pain subsided, the ECG shows T-wave inversion in V2 and biphasic T waves in V3-V5. This more closely resembles the less common presentation of Wellens syndrome with a biphasic T-wave pattern. This patient had a cardiac catheterization that showed a subtotal occlusion of the proximal left anterior descending (LAD) artery, which was stented, and the patient did well.
 
 
 
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