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Why we need continuous 12-lead ST segment monitoring in Wellens' syndrome Dr. Smith's ECG Blog: Why we need continuous 12-lead ST segment monitoring in Wellens' syndrome Friday, November 15, 2013 . This was a male in his 50's with a history of hypertension and possible diabetes mellitus who presented to the emergency department with a history of squeezing chest pain, lasting 5 minutes at a time, with several episodes over the past couple of months. It was worse on the evening prior (...) to presentation while lying in bed, then recurred and resolved while at rest just prior to arriving in the ED. Here is the first ED ECG, with no pain: Sinus rhythm. Computerized QTc = 419. There is very subtle Wellens' waves in V2, less subtle in V3, still less in V4. This is nearly diagnostic of Wellens' syndrome: pain that resolves, biphasic T-waves with preservation of R-waves. It extends all the way out to V6, and there is some T flattening in I and aVL, so this is probably a proximal LAD lesion. The ECG
Harbinger of infarction: Wellenssyndrome electrocardiographic abnormalities in the emergency department 23585602 2014 01 08 2018 11 13 1715-5258 59 4 2013 Apr Canadian family physician Medecin de famille canadien Can Fam Physician Harbinger of infarction: Wellenssyndrome electrocardiographic abnormalities in the emergency department. 365-6 Sowers Nicholas N Department of emergency medicine, Dalhousie University of Halifax, Halifax, NS. eng Case Reports Journal Article Canada Can Fam Physician (...) 0120300 0008-350X IM Aged Angina Pectoris etiology Coronary Artery Disease diagnosis Electrocardiography Emergency Service, Hospital Female Heart physiopathology Humans Myocardial Infarction diagnosis physiopathology Risk Factors Syndrome 2013 4 16 6 0 2013 4 16 6 0 2014 1 9 6 0 ppublish 23585602 59/4/365 PMC3625080 Am Heart J. 1982 Apr;103(4 Pt 2):730-6 6121481 Ann Emerg Med. 1999 Mar;33(3):347-51 10036351 Emerg Med J. 2009 Oct;26(10):750-1 19773507 Am J Emerg Med. 2002 Nov;20(7):638-43 12442245
Pseudo-Wellens' Syndrome due to Left Ventricular Hypertrophy (LVH) Dr. Smith's ECG Blog: Pseudo-Wellens' Syndrome due to Left Ventricular Hypertrophy (LVH) Monday, June 18, 2012 A 52 year old male presented with epigastric pain, continuing in the emergency department. He has a history of hypertension, and is on amlodipine. Thinking that epigastric pain might be an anginal equivalent, this ECG was recorded: There is LVH. There are T-wave inversions in aVL and V3-V6. The physicians were worried (...) about Wellens' syndrome and treated for ACS. He was placed on a nitroglycerine drip. Initial troponin was negative. A followup ECG was done 3 hours later. Perhaps slightly less T-wave inversion. Nonspecific. He was admitted. All troponins were normal. A formal echo showed concentric LVH and there was also a subtle abnormality which the echocardiographer thought suspicious for LAD distribution ischemia. So he underwent a coronary angiogram which was completely normal. This is not Wellens'. Why? 1
Wellen'sSyndromeWellensSyndrome Toggle navigation Brain Head & Neck Chest Endocrine Abdomen Musculoskeletal Skin Infectious Disease Hematology & Oncology Cohorts Diagnostics Emergency Findings Procedures Prevention & Management Pharmacy Resuscitation Trauma Emergency Procedures Ultrasound Cardiovascular Emergencies Lung Emergencies Infectious Disease Pediatrics Neurologic Emergencies Skin Exposure Miscellaneous Abuse Cancer Administration 4 Wellen'sSyndromeWellen'sSyndrome Aka: Wellen's (...) Suggests critical left anterior descending artery High risk for significant anterior wall in the coming days to weeks (regardless of symptoms) V. Resources Wellen'sSyndrome (Life in the FastLane) VI. References Images: Related links to external sites (from Bing) These images are a random sampling from a Bing search on the term "WellensSyndrome." Click on the image (or right click) to open the source website in a new browser window. Related Studies (from Trip Database) Related Topics in Examination
Red Flags in Electrocardiogram for Emergency Physicians: Remembering Wellens' Syndrome and Upright T wave in V1 We present a case of Wellens' syndrome together with upright T wave in lead V(1) in a man presenting with atypical chest pain, and we discuss the significance of its prompt recognition by the emergency physicians who are involved in the evaluation of patients with coronary artery disease in emergency departments.
Wellenssyndrome: a life-saving diagnosis. The diagnosis of acute coronary syndrome relies on clinical history, electrocardiographic (ECG) changes, and cardiac biomarkers; but within the spectrum of acute coronary syndrome, there exist subtle presentations that cannot afford to be overlooked. Wellenssyndrome is one such example, in which a patient can present with both ECG changes that are not classic for myocardial ischemia and negative cardiac biomarkers. The characteristic ECG findings (...) associated with Wellenssyndrome consist of deep, symmetric T-wave inversions in the anterior precordial leads. However, Wellenssyndrome can also present as biphasic T-wave inversions in those same ECG leads. The associated critical stenosis of the proximal left anterior descending artery carries an immediately life-threatening prognosis if not recognized promptly (Am Heart J. 1982;103[4 Pt 2]:730-736). We describe a case of a less common manifestation of Wellenssyndrome (type 1) followed
this as "biphasic T-waves in V3 and V4." There is also T-wave inversion in aVL. This is very suggestive of Wellens' syndrome with a proximal LAD lesion. A subsequent ECG was recorded: Not much changed The patient was admitted to observation. Her troponins [Ortho Clinical Diagnostics, Limit of detection is 0.012 mcg/L, 99% reference value ("positive" troponin) of 0.034 mcg/L] were less than 0.012, then 0.015, then less than 0.012. The ECG findings were not commented upon by the inpatient team, and the patient (...) very low 10% CV and can accurately measure changes below the 99% level. They may help diagnose unstable angina in the future. Case continued Later that day, the patient underwent an angiogram and had a 95% stenosis of the proximal LAD with thrombus, and another of the first diagonal off the LAD. Both were stented. Comment This is NOT Wellens' syndrome. In Wellens' syndrome , the T-waves are inverted when the patient is pain-free. The underlying pathology is that during the pain, the artery
. Let's go back in time It turns out he had been in the hospital less than a month prior with a NonSTEMI with Wellens' syndrome. Here is his ED ECG from that visit, after resolution of chest pain: Classic Wellens'. Patient is at high risk of closure of his LAD. The physicians wanted to do an angiogram, but in spite of pleading with the patient, the patient would not agree to undergo any further testing because he felt fine. They discharged him on aspirin and clopidogrel. This was his pre-discharge ECG (...) is the post cath ECG: Marked loss of R-waves with persistent ST elevation. These may resolve over time but are highly correlated with development of LV aneurysm. Echo 5 days later showed anterolateral, septal, and apical wall motion abnormalities and an EF of 40%. Peak troponin I was 176 ng/mL (very high). Learning Points: 1. As I've endlessly repeated here, LAD occlusion may be very subtle. Any delay in diagnosis can result in significantly worse outcome. 2. Wellens' syndrome is the result of reperfusion
Pseudonormalization of Wellens' Waves Dr. Smith's ECG Blog: Pseudonormalization of Wellens' Waves Friday, March 14, 2014 A male in his 60's complained of intermittent chest pain all day. He was vague as to whether there was active chest pain, but it was definitely better at the time I talked to him. Here is his initial ECG: There is minimal ST elevation and there are subtle T-wave inversions in V2-V5 , highly suggestive of Wellen s' syndrome. Is the ST Elevation normal? Very low R-wave (...) amplitude suggests NOT. See formula here: The QTc was 380 ST Elevation at 60 ms after the J-point in lead V3 = 1.5 mm R-wave amplitude in V4 = 2.5 QRS V2 = 15.5 mm 3-variable formula = 23.4 (equals cutoff of 23.4, consistent with LAD occlusion) 4-variable formula = 18.34 (above 18.2, consistent with LAD occlusion) In Wellens' syndrome, the artery is open. T-wave inversion, as I've pointed out countless times (and hope I'm not belaboring) is indicative of reperfusion of the infarct-related vessel. So
that the STE is new ischemia and that this is STEMI. The STEMI was not recognized, the patient was put on a nitroglycerine drip (as well as aspirin, heparin, and clopidogrel), and pain continued. A subsequent ECG was recorded at 1 hour: 1 hour. The T-waves in V1-V3 are inverting and in V4-V6 are flattening. This is some evidence of reperfusion; is it Wellens'? The ECG has the appearance of Wellens' waves, but the patient is not pain free, so it is not Wellens' syndrome . Continued pain in the context (...) Septal STEMI with lateral ST depression, then has collateral reperfusion resulting in Wellens' waves Dr. Smith's ECG Blog: Septal STEMI with lateral ST depression, then has collateral reperfusion resulting in Wellens' waves Wednesday, March 20, 2013 A middle-aged male presented with 1.5 hours of 8/10 chest pain associated with diaphoresis and vomiting. He has a prior history of untreated hypertension and hyperlipidemia, and is a current smoker. He called 911. Prehospital vitals were normal
be sobering. I have seen cases of Wellens' syndrome that were ignored because of either negative troponins or normal echo or both and the patient did not get an angiogram and had a bad outcome. Wellen'ssyndrome is a Reperfusion syndrome. All of Wellens' cases in his studies (1, 2) had all of: 1) preserved R-waves 2) resolution of pain 3) restored flow to the anterior wall through either a) an open artery or b) collateral circulation. This is a rare case in which we can prove that the Wellens' waves (...) experience, all Wellens' with significant myocardial infarction have , so that the presence of type A or type B waves, I believe, are simply a matter of the timing of recording and the rapidity of evolution. In this case, the duration of ischemia was so brief that there was no such evolution, and there was near-normalization. When there is extremely brief ischemia, , , it may entirely reverse, especially in unstable angina (negative troponins). Lessons: 1. Wellens' syndrome represents a state
. Physical Inactivity e99 5. Nutrition e119 6. Overweight and Obesity e138 Health Factors and Other Risk Factors 7. High Blood Cholesterol and Other Lipids e161 8. High Blood Pressure e174 9. Diabetes Mellitus e193 10. Metabolic Syndrome e212 11. Kidney Disease e233 12. Sleep e249 Cardiovascular Conditions/Diseases 13. Total Cardiovascular Diseases e257 14. Stroke (Cerebrovascular Disease) e281 15. Congenital Cardiovascular Defects and Kawasaki Disease e327 16. Disorders of Heart Rhythm e346 17. Sudden (...) States and globally. The Statistical Update also presents the latest data on a range of major clinical heart and circulatory diseaseconditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease [CHD], heart failure [HF], valvular disease, venous disease, and peripheral arterial disease) and the associated outcomes (including quality of care, procedures, and economic costs). Since 2007, the annual versions of the Statistical Update have
Management 91 11. FOLLOW-UP OF PATIENTS WITH STABLE CAD 93 12. PRE-OPERATIVE ASSESSMENT FOR ELECTIVE NON-CARDIAC SURGERY 95 13. MONITORING AND QUALITY ASSURANCE 97 REFERENCES 98 ACKNOWLEDGMENTS 123 DISCLOSURE STATEMENT 123 SOURCES OF FUNDING 123 6 Rationale: Coronary Artery Disease (CAD) covers a wide spectrum from asymptomatic individuals to patients with stable CAD, Acute Coronary Syndromes (ACS) and Sudden Cardiac Death (SCD). This Clinical Practice Guidelines (CPG) on Stable CAD is directed (...) Disease Type of Study: ? Systematic review and meta analysis ? Randomised Controlled Studies ? Cohort studies Thus, there were numerous clinical questions formulated. E.g. of some of these Clinical Questions: What is the validity (sensitivity, specificity and predictive value) of an Exercise ECG in an asymptomatic individual with no previous medical illness, in the diagnosis of CAD? What is the validity (sensitivity, specificity and predictive value) of an Exercise ECG in diagnosing CAD
significance? Image from: https://www.aliem.com/2013/06/wellens-syndrome-on-your-radar/ “A notable subgroup of ischemic T wave inversions is associated with Wellenssyndrome, which classically manifests with either deep symmetrical T wave inversions (type I) or biphasic T wave changes (type II) in the anterior precordial leads. The presence of biphasic T waves is suggestive of ischemic heart disease. Other electrocardiographic features include isoelectric or minimally elevated (<1 mm) ST segments (...) CRACKCast E078 – Acute Coronary Syndromes Part A CRACKCast E078 - Acute Coronary Syndromes Part A - CanadiEM CRACKCast E078 – Acute Coronary Syndromes Part A In , by Adam Thomas May 15, 2017 This episode of CRACKCast covers Rosen’s Chapter 76, Acute Coronary Syndromes. Part A of this episode covers the essentials of Acute Coronary Syndromes, including DDx, pertinent ECG findings and the ever important STEMI equivalents. Shownotes – Rosen’s in Perspective Ischemic heart disease and CAD
Atypical Presentation of Acute Coronary Syndrome and Importance of Wellensâ€™ Syndrome BACKGROUND Acute coronary syndrome (ACS) is a common and potentially life-threatening condition encountered in emergency departments. Despite its dreaded nature, nearly one-third of ACS present without chest pain and may mislead clinicians. Additionally, Wellens' syndrome is a pre-infarction stage of significant proximal left anterior descending (LAD) artery stenosis, which can lead to extensive anterior wall (...) the importance of awareness of atypical presentation of ACS and importance of Wellens' syndrome. We also discuss the incidence of craniofacial symptoms of ACS, and the epidemiology, pathophysiology, management, and prognosis of Wellens' syndrome.
." There is also T-wave inversion in aVL. This is very suggestive of Wellens' syndrome with a proximal LAD lesion. A subsequent ECG was recorded: There is now a bit less of the biphasic T-waves. The patient was admitted to observation. Her troponins [Ortho Clinical Diagnostics, Limit of detection is 0.012 mcg/L, 99% reference value ("positive" troponin) of 0.034 mcg/L] were less than 0.012, then 0.015, then less than 0.012. Since these are all below the 99% reference, and thus they are technically "negative (...) % stenosis of the proximal LAD, and another of the first diagonal off the LAD. Both were stented. This is an unusual case of "Wellens' syndrome." The amount of myocardial infarction (necrosis), as measured by troponin, was so small that the T-waves did not have the typical evolution (T-waves become deeper and more symmetric) seen here: Instead, the T-waves were dynamic, inverting, then normalizing. One might be tempted to call these normalizing T-waves "pseudonormalization." But this term is the name
% of all patients investigated for ACS will not have this diag- nosis con?rmed . In unselected patients presenting with acute chest pain to the ED in the Australian setting, the prevalence of different diagnostic groups are: 2-5% ST elevation MI (STEMI), 5-10% Non-STEMI (NSTEMI), 5- 10% UA, 15-20% other cardiac conditions and 50-70% non-cardiac diseases [5–7]. The costs and burden of the diagnostic process to patients, clinicians and the healthcare system are signi?cant. 1.2. Contemporary Outcomes (...) be considered include gastro-oesophageal pathology, pleur- itis and other pulmonary disease, muscular and skeletal causes including costochondritis, and herpes zoster. In addi- tion, patients with myocardial oxygen supply–demand mis- match due to non-atherosclerotic and non-coronary conditions (e.g. Type 2 MI, Refer to Section 3.1.3) may also present with chest pain but who require a different manage- ment pathway to patients with type 1 MI (i.e. plaque rupture). 2.3. Initial Clinical Management Practice
) sports (Class IIb; Level of Evidence C) . Elevated Pulmonary Vascular Resistance in CHD Patients with pulmonary vascular disease and CHD are at risk of sudden death during sports activity. In those with shunts (commonly septal defects or complex CHD), cyanosis is usually present at rest (Eisenmenger syndrome) and worsens with exercise. Most of these patients self-limit their activity, and they should not participate in competitive sports, with the exception of low-intensity (class IA) sports (...) Eligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities: Task Force 4: Congenital Heart Disease Eligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities: Task Force 4: Congenital Heart Disease | Circulation Search Hello Guest! Login to your account Email Password Keep me logged in Search March 2019 March 2019 March 2019 March 2019 March 2019 February 2019 February 2019 February 2019 February