History
Wellens syndrome represents stenosis of the proximal left anterior descending coronary artery (LAD), and patients typically present with symptoms or complaints consistent with coronary artery disease (CAD). Generally, the history is most consistent with unstable angina. Angina can have varying presentations, but the classic presentation includes the following complaints:
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Chest pain described as pressure, tightness, or heaviness
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Pain that is typically induced by activity and relieved by rest
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Radiation of pain to the jaw, shoulder, or neck
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May experience multiple associated symptoms, including (but not limited to) diaphoresis, nausea, vomiting, and fatigue
Elderly, diabetic, and female patients are more likely to present with atypical symptoms.
Physical Examination
Physical examination does not provide any indicators that would give the examiner strong grounds for suspecting Wellens syndrome specifically. However, the results of the patient’s examination may show evidence of ongoing ischemic injury (eg, congestive heart failure [CHF]).
In addition, most of the electrocardiographic (ECG) changes are recognized when the patient is pain-free, which again underscores the importance of a repeat pain-free ECG in the emergency department.
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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.
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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.
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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.
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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.
