Diagnostic Considerations
Potential diagnostic pitfalls with Wellens syndrome include the following:
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Failing to recognize Wellens syndrome T-wave changes on electrocardiography (ECG)
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Ordering a stress test without recognizing risks (see Workup); this may provoke a large anterior wall myocardial infarction (MI) [3]
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Underestimating the seriousness of the ECG finding in a pain-free patient
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Failing to properly admit or consult cardiology on patients with the characteristic ECG changes
In addition to the conditions listed in the differential diagnosis (see below), other conditions to be considered include the following:
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Central nervous system injury
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Persistent juvenile T-wave pattern
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Left ventricular hypertrophy
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Bundle-branch block
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Digitalis effect
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Acute myocarditis
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Preexcitation syndromes
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Later stages of pericarditis
Differential Diagnoses
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Acute Coronary Syndromes
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Atherosclerosis
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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.
