Wellens Syndrome Treatment & Management

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 unless clearly recommended by cardiologists.

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.

Because Wellens syndrome occurs because of stenosis of the proximal 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.

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, when appropriate

• ECG (initially) – Serial examinations and pain-free tracings may be helpful

• Telemetry monitoring

• Chest radiography

• Laboratory studies (see Laboratory Studies)

• Aspirin

• Consideration should be given to providing  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. ^{[11, 12, 13]} 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. ^{[14, 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