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Wellens Syndrome

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181. MMPPC Outpatient Clinical Protocol 2016

is to determine the efficacy of the MMPPC controller in adolescents and adults with type 1 diabetes in a hotel setting. Condition or disease Intervention/treatment Phase Type 1 Diabetes Device: MMPPC algorithm artificial pancreas Phase 2 Detailed Description: This study trials a prototype artificial pancreas system that consists of a Roche insulin pump, a Dexcom continuous glucose monitor (CGM), and an experiential MMPPC (multiple model probabilistic predictive control) algorithm housed on an android cell (...) aspect of the protocol Subject is currently participating in another investigational device or drug study within 30 days or 5-half lives of the drug. Subject has a history of any cardiac or vascular disorder including, but not limited to, myocardial infarction, unstable angina, coronary artery bypass surgery, coronary artery stenting, transient ischemic attack, cerebrovascular accident, angina, congestive heart failure, arrhythmia or thromboembolic disease An EKG will be obtained on subjects who

2016 Clinical Trials

182. Dynamic T-wave inversions in the setting of left bundle branch block. (Abstract)

Dynamic T-wave inversions in the setting of left bundle branch block. We illustrate the case a patient with left bundle branch block (LBBB) and electrocardiogram (ECG) changes consistent with those described in Wellens' syndrome. The characteristic ECG findings of Wellens' syndrome identify patients who have a particularly high rate of important coronary events in the near future, however these findings have previously been described only in the setting of normal conduction. A review of Wellens (...) ' syndrome, its criteria and pathophysiology, and its proposed appearance in the setting of LBBB is presented.Copyright © 2016 Elsevier Inc. All rights reserved.

2016 American Journal of Emergency Medicine

183. A warning sign. Full Text available with Trip Pro

symptom resolution showed biphasic T wave inversions in V2 and V3 which prompted an emergent coronary angiogram that revealed 90% occlusion of the proximal LAD. The immediate recognition of Wellens' pattern lead to emergent coronary revascularization and prevention of acute myocardial infarction in our patient. Clinicians should be aware of this syndrome so that prompt invasive therapy can be done to avoid evolution into MI and subsequent left ventricular dysfunction.Copyright © 2016 European

2016 European journal of internal medicine

184. Persistent Juvenile T-wave Pattern

are the symmetric T-waves of Wellens' Pattern B syndrome: Figure 5. Note the near perfect symmetry of V2 and V3. This is NOT normal, not PJTWP. The ECG of another healthy 3 year-old, taken from Chan et al. (2) Figure 6. Notice the inverted T-waves in V1-V3 are slightly asymmetric. An example of a juvenile T wave pattern in a healthy 11 year-old male is provided in an article by Sharieff and Rao:(3) Figure 7. Here the T inversion is limited to V1 and V2; it is slightly asymmetric. Defining “persistent” juvenile (...) PD, Kanaya AM, et al. Differences in Medical Care and Disease Outcomes Among Black and White Women With Heart Disease. Circulation 2003;108(9):1089-1094. doi:10.1161/01.CIR.0000085994.38132.E5. Posted by Steve Smith at Labels: Reactions: 15 comments: Well done discussion by Brooks Walsh (!) - who confronts key issues on distinction between PJTWP vs other potentially more serious conditions. I'll expand on a few points: "Symmetry" of T waves is in the eyes of the beholder. Whether one calls a T

2015 Dr Smith's ECG Blog

185. A 30 year old African American with Chest pain and T-wave Inversion

. The worry here was that it was Wellens' syndrome. BTWI has a comparatively short QT. My hand-measured, Bazett-corrected QTc in both of them is 415 ms. The apparent increase on the 2nd is because the raw QT is longer, but is limited by the correction. Wellens' is generally (but not always!) longer. The giveaways are the tall R-waves in the affected leads, with minimal S-waves, and the presence of J-waves, especially in V3-V6 on the second ECG. U-waves are a common feature of early repolarization, which

2015 Dr Smith's ECG Blog

186. A Middle-Age Male with Chest Pain that Recurs in the ED

you is that when the patient had arrived pain free , he had this ECG recorded: Here there is subtle terminal T-wave inversion in V2, and a bit in V3, typical of early Pattern A Wellens' waves. So the first ECG is not normal; it is " pseudonormal ." It triggered the recording of serial ECGs (sorry, not available) which showed increasing ST elevation diagnostic of LAD occlusion. So this was Wellens' syndrome, a state of spontaneous reperfusion of the LAD, manifesting with "reperfusion T-waves" and R (...) -wave preservation after an episode of closure of the LAD. Thus, the patient presents pain free after an episode of angina. The importance of Wellens' syndrome is that the artery can close off again at any moment, in which case the inverted T-waves will become upright again and look normal. This is called "pseudonormalization". The first ECG was recorded so soon after re-occlusion of the artery that this ECG shows no signs of occlusion other than pseudonormalization, which requires comparison

2015 Dr Smith's ECG Blog

187. New 40 minute lecture on T-wave Inversion

wave in both ECGs?? I think they are within normal limits 40:08 which wall is involved????????? Inferior and posterior Hi Smith, As I am about to complete my first year of residency (cardiology) I discussed T wave inversions and Wellens Syndrome with my fellow colleagues. One of my colleague is just doing a six month rotation in our Cardiology department and asked an intersting questions. With a patient with Wellens Syndrome, now pain free, after 6h from the first pain episode (...) is it possibile that the high sensible troponins stay negative? In that case (negative high sensisble troponins) should the patients be still sent to the cath lab or sent home and undergo an elective II level imaging test (RM/ TC)? My opinion on the latter is that with a pathological ECG and no clear cause (unseen/unknown wellens ECG pattern) patient should stay hospitalized. I'm interested in what you think about these two questions. Thank you for your help and congratulations on your excellent blog.

2015 Dr Smith's ECG Blog

188. Ventricular Fibrillation, Resuscitation, and Hyperacute T-waves: What does the Angiogram show?

There is inferior ST elevation with reciprocal ST depression in aVL, diagnostic of inferior injury. The hyperacute T-waves in V4-V6 are diminished and there is less ST elevation. The cath lab was activated. He was given aspirin and heparin. Prior to transport, another ECG was recorded. This one is 25 min after first prehospital, and 12 min after the first ED ECG: There is nearly complete resolution of all injury pattern Angiogram showed no culprit, but did show severe 3 vessel disease, with 100% chronic LAD (...) and RCA occlusions, and chronic 75% circumflex. All territories were supplied by collaterals from the circumflex! An immediate Echo showed distal inferior and distal septal, anterior, and apical wall motion abnormality, with EF of 55-60%. The patient was prepared for CABG. Here is an ECG 15 hours after first: Some reperfusion T-wave inversion in V5 and V6. Troponin I peaked at 0.59 ng/mL. ECG recorded 24 hours after first More pronounced reperfusion waves in V3-V6 (Lateral Wellens' waves) The patient

2015 Dr Smith's ECG Blog

189. The pathogenesis of reversible T-wave inversions or large upright peaked T-waves: Sympathetic T-waves. (Abstract)

, Wellens or coronary and cardiac memory T waves. During the last 15 years, the reversible TWI and LUPTW in association with P-QTc have been described as characteristic ECG features in takotsubo syndrome (TS), which also may be triggered by the same aforementioned acute cardiac and non-cardiac disease entities. The pathogenesis of these reversible T-wave changes is not clear-cut. In this manuscript, substantial evidences for a causal link between the local cardiac sympathetic disruption (...) The pathogenesis of reversible T-wave inversions or large upright peaked T-waves: Sympathetic T-waves. Reversible electrocardiographic (ECG) repolarization changes including T-wave inversions (TWI), large upright peaked T-waves (LUPTW) and prolongation of the corrected QT interval (P-QTc) have been reported in association with myriads of acute cardiac and non-cardiac diseases. Through the last 70 years, the TWIs have been described under different terms as; cerebral, giant, global, canyon

2015 International journal of cardiology

190. The Set-Point Study: Evaluating Effects of Changing Glucose Target on Bionic Pancreas Performance

is achieved by an insulin-only bionic pancreas with minimal hypoglycemia. Condition or disease Intervention/treatment Phase Type 1 Diabetes Type 2 Diabetes Device: Bionic Pancreas Other: Usual Care Not Applicable Detailed Description: We have two specific aims: Aim 1 is to conduct an outpatient study testing multiple configurations of the bionic pancreas in 24 adult subjects with type 1 diabetes in a random cross-over study versus usual care with an insulin pump. These bionic pancreas configurations (...) , but not limited to, evidence of active ischemia, prior myocardial infarction, proximal LAD critical stenosis (Wellen's sign), prolonged QT interval (> 440 ms). Non-specific ST segment and T wave changes are not grounds for exclusion in the absence of symptoms or history of heart disease. A reassuring evaluation by a cardiologist after an abnormal EKG finding may allow participation. Congestive heart failure (established history of CHF, lower extremity edema, paroxysmal nocturnal dyspnea, or orthopnea) History

2015 Clinical Trials

191. Research and Reviews in the Fastlane 125

and the healthcare system. According to the WHO globally, harmful use of alcohol causes approximately 3.3 million deaths every year (or 5.9% of all deaths), and 5.1% of the global burden of disease is attributable to alcohol consumption. This review examines the effects of alcohol overconsumption associated with critical illness and severe injury. Compared with patients without alcohol overuse, has critically ill patients with alcohol overuse complex illness with greater complications, longer hospital both ICU (...) evidence). Recommended by Lauren Westafer Cardiology Macias M et al. The electrocardiogramin the ACS patient: high-risk electrocardiographic presentations lacking anatomically oriented ST-segment elevation. Am J Emerg Med 2015. PMID: This review focuses on the 5 of the more common, yet lesser known, high-risk ECG patterns in the ACS patient that you gotta know: 1. 1st Diagonal Branch of LAD Artery 2. de Winter Presentation 3. Left Main Coronary Artery Occlusion 4. WellensSyndrome 5. Posterior Wall MI

2016 Life in the Fast Lane Blog

192. Sudden Left Trapezius Pain and Syncope

similar to the second ECG in your post on June 17th. The inferior changes looked like typical early repol but with the changes in aVL, took on a bit more of a worrying look. However angiogram showed only an LAD lesion, no disease in RCA or LCX. I'd like to see it. T-wave inversion in aVL can be acute inferior (reciprocal to inferior STEMI), or it can be reperfusion of the lateral wall (proximal LAD Wellens). Steve Dear doctor.,I have observed that there is st elevation in inferior. leads (...) or pericarditis. Another great case Steve - the reperfused ECG seems to have some 'posterior reperfusion T-waves' as well! Sam Indeed, Sam! matthias Is there any explanation for the T waves V1-V3 getting taller over the course of time? and thanks a lot for this great blog!! Matthias Yes! Posterior Reperfusion T-waves. Our paper on the topic:

2014 Dr Smith's ECG Blog

193. Dyspnea on Exertion and a Positive Troponin

on the ECG in PE below) I was sent this ECG without clinical information and asked what it was. My first thought was "pulmonary embolism." All because of the above ECG findings. Here are other cases of acute right heart strain: Primer on the ECG in Pulmonary Embolism: These are findings of acute right heart strain, and could be seen in any condition which results in a rapid rise in pulmonary artery pressure. This includes hypoxia because of "pulmonary hypoxic vasoconstriction" The ECG is not sensitive (...) for PE, but when there are findings such as S1Q3T3 or anterior T-wave inversions, or new RBBB, then they have a (+) likelihood ratio and the S1Q3T3, or even just the T3, may help to differentiate Wellens' from PE. found normal ECGs in only 3 of 50 patients with massive PE, and 9 of 40 with submassive PE. Today, however, that number would be higher because we diagnose more of the submassive PEs that have minimal symptoms. studied ECG findings of PE in 6049 patients, 354 of whom had PE. They found

2014 Dr Smith's ECG Blog

194. Unstable Angina: Dr. Braunwald asks if it is time for a Requiem

to the waiting room with a "normal" EKG who later coded in the waiting room. This is also where the ST elevation showed up in your second EKG... Yes, but this is a common nonspecific finding in ECGs with deep S-waves. In first ecg there is t wave inversion, is it Wellen's t wave Or if during pain if this ecg recorded than what is importance of t wave inversion in this case? The T-wave inversion is very nonspecific. It does not look like Wellens'. Also, Wellens' is a syndrome, not an ECG finding: Typical (...) a stat formal echo which showed hyperdynamic heart and anterior wall motion abnormality but with EF of 85%. There was no serious valvular disorder. Her pain resolved. She ruled out for MI with contemporary high sensitivity troponins. The next morning she had a VT arrest and was resuscitated. Here is her post resus ECG: Large ST elevation. It has a very odd morphology, even mimicking Brugada and Hyperkalemia, but it must be assumed to be LAD occlusion She was taken for cath and had a 100% LAD

2014 Dr Smith's ECG Blog

195. Waxing and Waning Chest Pain

in by troponins, the infarct related artery is closed about 25-30% of the time. These patients have higher biomarkers, worse LV function, and higher mortaility than patients whose artery is open. 1. Wang T et al. Am Heart J 2009;157(4):716-23. 2. From AM, et al. Am J Cardiol 2010;106(8):1081-5. 3. Pride YB et al. JACC: Cardiovasc Interventions 2010; 3(8):806-11. Lessons : 1. Wellens' syndrome has analogous findings in the inferior and/or lateral walls. 2. T-wave changes of the posterior wall record (...) Waxing and Waning Chest Pain Dr. Smith's ECG Blog: Waxing and Waning Chest Pain Tuesday, April 8, 2014 A male in his 50s presented with Chest pain on and off during the day. At the time of presentation, he had only some jaw pain. An ECG was recorded: What do you think? There are inferior and lateral T-wave inversions (reperfusion T-waves, analogous to Wellens' waves which were described in the LAD distribution, V2-V4, but this also applies also to other coronary distributions). There is also ST

2014 Dr Smith's ECG Blog

196. A Non STEMI that needs the cath lab now.

now The diagnosis is acute MI, but not STEMI. There is slight ST elevation in lead III with reciprocal ST depression in aVL. The T-wave is inverted in III, indicating reperfusion (what I like to call "inferior Wellens' syndrome). There is no Q-wave, so this is unlikely to be old MI, and more likely to be acute NonSTEMI of the inferior wall. I saw these ECGs, and since there was no immediate urgency, allowed the resident to manage it without any comment. However, he did not see the abnormality (...) ischemia, when the primary ECG manifestation is ST elevation with reciprocal ST depression, and when it is ST depression due to subendocardial ischemia, with reciprocal ST elevation Thanks for the explanation , Prehospital ECG shows "slight ST elevation in lead III with reciprocal ST depression in aVL. The T-wave is inverted in III, indicating reperfusion (what I like to call "inferior Wellens' syndrome)" as you mentioned in blog. Sir, is there is subtle ST depression in lead V2 in same ECG along

2014 Dr Smith's ECG Blog

197. 45 year old with chest pain

, as seen in Figure 3. There is new T-wave inversion in I, aVL, V4-V6. There is terminal T-wave inversion (biphasic) in V2 and V3, but complicated by the U-waves seen in these leads. This T-wave inversion represents a form of Wellenssyndrome, indicating spontaneous reperfusion of a brief left anterior descending coronary occlusion. This time troponin was positive, and the patient underwent coronary angiography, which showed severe subtotal left anterior descending artery disease and 70% left main (...) to acute coronary syndrome (ACS). Remember – not all ACS has a positive troponin! When negative, it is – of course – called “unstable angina.” It usually presents with a normal or nonspecific ECG, with ST-depression, or T-wave inversion – but unstable angina may also present with transient ST-segment elevation . Perhaps more disgruntling, transient ST-elevation does not always result in a positive troponin. The ischemia may resolve so quickly that there is both no wall motion abnormality

2014 Dr Smith's ECG Blog

198. It is Far too Early for a Requiem for Unstable Angina

had chest pain just prior to arrival in the ED, but it resolved prior to physician evaluation. He did use cocaine a few days prior. He had blood pressures in the 170/100 range. Here is his initial ECG: There is terminal T-wave inversion in V2-V5, highly suggestive of "Wellens' syndrome." Patient had pain, is pain free, has intact R-waves, and terminal T-wave inversion (Wellens' Pattern A) There was no further pain, but a second ECG was recorded 1 hour later: There is some evolution of T-wave (...) inversion (V3 has a deeper negative deflection), increasing suspicion for Wellens' syndrome. The ED was concerned about "Wellens' pattern," and gave aspirin, clopidogrel, and heparin. He was not given anything for his blood pressure. He was admitted to the hospital. The consultants were very worried as well, and discussed angiogram vs. stress test in the morning. Comment: when a patient has cardiac ischemia and is hypertensive, the blood pressure should be controlled. There are many choices. One

2014 Dr Smith's ECG Blog

199. What is the infarct artery? (Complex analysis, in this case)

depression in aVL. What direction is the ST vector? There is diffuse ST elevation, except towards leads I, aVL and V2: To the right Inferior Posterior Left inferolateral Left anterior Right anterior Angiography Results: No disease in LAD or circ RCA dominant with acute thrombosis Thrombectomy and stent. Good outcome. Posted by Steve Smith at Labels: Reactions: 9 comments: Anonymous Very nice case. I wonder how were the systolic function of both ventricles and If it was some acute mitral regurgitation (...) critical STEMI. Thanks! Predicting the Culprit Lesion in Acute Inferior ST-Elevation Myocardial Infarction Based on Wellens’ Criteria and Tierala’s Algorithm This is one of my favourite posts on this blog, thanks Steve for sharing, great case and well explained. Thanks, Jay! Subscribe to: Recommended Resources , . Dr. Stephen W. Smith is a faculty physician in the at Hennepin County Medical Center (HCMC) in Minneapolis, MN, and Professor of Emergency Medicine

2014 Dr Smith's ECG Blog

200. ST Elevation: is it due to old MI (LV aneurysm) or to acute STEMI?

, then it is likely to be acute STEMI. Rule 2: if the sum of T-wave amplitudes in V1-V4 divided by the sum of QRS amplitudes in V1-V4 is greater than 0.22 , then it is likely to be STEMI, not LVA Outcome The patient was cooled and taken to the cath lab. There, a long acute mid-LAD 95% lesion with thrombus and low flow was seen and opened and stented. There was also complex 3-vessel disease but the acute lesion was in the LAD. Subsequently, records from another hospital revealed that he had a history of ischemic (...) /is-this-wellens-syndrome.html It is as prevalent as an upright T-wave. I have many more. Steve thank you dr steve for such anice and amazing case Thanks for your comment. Because of the T-wave inversion and too high STE, I would refer to Cath-lab. My question: is there other differentials between aneurysm and STEMI with aneurysme than the formula? I asked Nicolas to clarify, and this was his question: I should say, you use the formula, but without, do you have other signs to get the right diagnosis? Yes

2014 Dr Smith's ECG Blog

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