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Wellens Syndrome

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81. Electrocardiographic Early Repolarization

, Szél T, Hu D, Barajas-Martínez H, Antzelevitch C . Mechanisms underlying the development of the electrocardiographic and arrhythmic manifestations of early repolarization syndrome. J Mol Cell Cardiol . 2014 ; 68 :20–28. doi: 10.1016/j.yjmcc.2013.12.012. Wellens HJ . Early repolarization revisited. N Engl J Med . 2008 ; 358 :2063–2065. doi: 10.1056/NEJMe0801060. Ghosh S, Cooper DH, Vijayakumar R, Zhang J, Pollak S, Haïssaguerre M, Rudy Y . Early repolarization associated with sudden death: insights (...) and developed recommendations based on the results of the current literature. We searched MEDLINE (via PubMed), EMBASE, and the Cochrane Library to identify relevant primary scientific articles, guideline statements, and review articles in the literature. Search terms included, but were not limited to, early repolarization, J-point elevation, J wave, Haissaguerre syndrome, sudden cardiac death, idiopathic ventricular fibrillation, ventricular fibrillation, cardiac repolarization reserve, sudden unexplained

2016 American Heart Association

82. Chest pressure during exertion, evolution of inverted T-waves and Troponins. Surprise Angiogram.

), that had resolved. Very worrisome T-wave inversion in V2, V3. Looks like Wellens' syndrome and is changed from the ECG 9 days prior (below). The patient was to be admitted for this, but left the ED without warning. Baseline 10 days prior to ECG 6 (ECG 7) I was sure that all these ECGs pointed to a reperfused high lateral MI, probably a first diagonal (since V2 was involved.) Angiogram : Normal coronary arteries! Interpretation : It is uncertain what the etiology was. Spasm? Thrombosis with complete

2018 Dr Smith's ECG Blog

83. If you had recorded an ECG during chest pain, what would it have shown?

. 1982 Apr;103(4 Pt 2):730-6. de Zwaan C et al. . Am Ht J 117(3): 657-665; March 1989. (Some later authors ignored Wellens own classification of "Pattern A" and called this "Type" B!! -- let's go back to Wellens' own classification) Here is an example of the mis classification: This is Wellens' syndrome: Since the patient had anginal chest pain that is now resolved, it meets the criteria for Wellens' syndrome ( criteria : resolved anginal chest pain, typical Wellens' waves in LAD distribution (...) with preserved R-waves, absence of LVH which can cause pseudoWellens' waves). See these posts for Wellens' mimics: Case continued Unlike many cases of Wellens' syndrome, this patient actually presented with active pain . So you are going to get to see what the ECG would have shown had you recorded one during pain! This was the first ECG (ECG #1) recorded during pain : This shows ST elevation and hyperacute T-waves in the LAD distribution. This is highly suspicious for acute LAD occlusion. It even meets STEMI

2018 Dr Smith's ECG Blog

84. T-wave inversions and dynamic ST elevation

, "Wellens' syndrome" requires clinical factors in addition to ECG findings, including chest pain which resolved prior to recording of the ECG. Wellens' syndrome is not diagnosed during ongoing pain, as this would not be consistent with reperfusion (which should produce resolution of pain). On the ECG Wellens' syndrome also requires that there are preserved R-waves in the precordial leads. Below I have reproduced a list of findings of BTWI from a series of other blog posts on this topic on this site (...) , and we will go through each one with respect to the first presentation ECG: 1. There is a relatively short QT interval (QTc less than 425) YES . Computerized QTc in this case was 424 msec. 2. The leads with T-wave inversion often have very distinct J-waves YES . J-waves are present in V4-6, as well as II, III, aVF. 3. The T-wave inversion is usually in leads V3-V6 (in contrast to Wellens' syndrome, in which they are V2-V4) Here the TWI is in leads V3-4 only. So this doesn't really distinguish. Also

2018 Dr Smith's ECG Blog

85. Besides the Nonspecific T-wave Inversion in aVL, What Else is Abnormal on this ECG?

an episode of unresponsiveness. Previous ECG: First ECG with arrows (again) Slight STD in inferior and lateral leads, some STE in aVL, and profound negative U-waves in V3-V5. After Reperfusion of LAD: Reperfusion T-waves (Wellens' waves) Short Summary of the U-wave [Adapted from one of my chapters (in the ACS section, which I edited) in Critical Decisions in Emergency and Acute Care Electrocardiography. There are some contributions by Farkas Laszlo.] Note: The research on this topic is not of the most (...) long qt syndrome, left circumflex myocardial infarction. Usually, U wave has the same polarity as the T wave. According to earlier findings discordance between T and U and concordant negative T and U wave can also predict hypertension or myocardial ischaemia. In the appropriate clinical context, an increase in U-wave amplitude in the precordial leads may raise suspicion of posterior ischemia (due to an RCA or LCX lesion). This could be considered the mirror image of a negative U-wave. Here

2018 Dr Smith's ECG Blog

86. A crashing patient with an abnormal ECG that you must recognize

inversions can be very similar in anterior reperfusion syndrome (Wellens). It is also true that anterior and inferior T-wave inversion could be consistent with reperfusion of a type III wraparound LAD occlusion, despite the fact that . However, in reperfusion (Wellens'), the symptoms are resolved at the time of the ECG. Thus, it is critical to compare the ECG with the symptomatic state of the patient! Differences of Pulmonary Embolism T-waves from Wellens' T-waves: 1. Wellens' is a syndrome of a painless (...) wave with a convex upward ST segment morphology, ST segment strain morphology in the inferior and anterior leads leading to deep symmetric T-wave inversion. Why is it not Wellens??? (Wellens pattern is a term which refers to coronary reperfusion morphology in the anterior leads) The best answer is because the entire gestalt of the ECG shows acute right heart strain instead, and just does not look like Wellens after you've seen Wellens hundreds of times. It is true that the morphology of the T-wave

2018 Dr Smith's ECG Blog

87. An athletic 30-something woman with acute substernal chest pressure (PubMed)

— but that all chest pain had resolved at the time of presentation — and, that instead of ECG #1 being her initial tracing, that ECG #4 was her initial tracing . If this were the case, the appearance of the ST-T waves in the mid-chest leads of ECG #4 would be consistent with Wellens’ “Syndrome” — and would serve as an indicator of a tight, proximal LAD lesion in need of revascularization. Posted by Steve Smith at Reactions: No comments: Post a Comment Subscribe to: Recommended Resources , . Dr. Stephen W (...) to the angiographer as if it was a spontaneous coronary artery dissection . It seems that there was some uncertainly about this. The lesion was stented. ECG at time 19 hours after cath: Wellens' Pattern A T-waves are present (terminal T-wave inversion) Pattern A is in contrast to Pattern B, which is a further evolutionary stage of Wellens and is more deep and symmetric. These are reperfusion T-waves (the same thing as Wellens' waves) Echocardiogram Regional wall motion abnormality-distal septum and apex. Regional

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2018 Dr Smith's ECG Blog

88. Chest pain and T-wave inversion in lead V2

over age 14 but younger than 30. It is common in young women (these are the typical juvenile T-waves, link to relevant post above). T-wave inversion in V2 occurs in many pathologies, including posterior MI, pulmonary embolism, Wellens' syndrome. It is one of the minor criteria for arrhythmogenic right ventricular dysplas ia (" Minor: Inverted T-waves in right precordial leads V1-V2") Here is my list of Normal and Pathologic T-wave inversion: • Normal t wave vector is leftward, inferior and anterior (...) immediately saw that the computer was incorrect, but I found 2 abnormalities. What are they? I showed this to several physicians. They were worried about the T-wave inversion in V2. One mentioned "Wellens' waves" Another asked: "Are these juvenile T-waves?" (very good question!) For more on this: What do you think? I keep getting response tweets that T-wave inversion in V2 is normal. It is not normal. It is not necessarily pathologic, but it is not normal. It occurs normally in approximately 1% of males

2018 Dr Smith's ECG Blog

89. Two cases of ST Elevation with Terminal T-wave Inversion - do either, neither, or both need reperfusion?

. Three serial troponins were undetectable. His serial ECGs did not change. He was discharged home. Learning Points: There are many causes of ST elevation, terminal T-wave inversions, and both simultaneously. Experience with the cases on this blog can teach you how to differentiate them. Wellens syndrome (or reperfusion in general) is an important cause of terminal T-wave inversions. See these cases below for examples. However, Wellens' syndrome includes resolution of chest pain and preservation of R (...) -waves, in addition to T-wave inversion. Thus, this second case would not be an example of Wellens' syndrome. Also see below for more cases of LV aneurysm morphology: References: T/QRS ratio to differentiate anterior STEMI from anterior LV aneurysm: 1. Papadakis M, Carre F, Kervio G, et al. The prevalence, distribution, and clinical outcomes of electrocardiographic repolarization patterns in male athletes of African/Afro-Caribbean origin. Eur Heart J. 2011;32(18):2304-2313. doi:10.1093/eurheartj

2018 Dr Smith's ECG Blog

90. Timing of revascularization in patients with transient STEMI: a randomized clinical trial

segments"), it is not unequivocally necessary to activate the cath lab emergently. This might extend to Wellens' syndrome, which is really and transient STEMI in which the ST Elevation is not recorded. In this trial, 142 patients with transient STEMI were randomized to emergent vs. next day angiogram with PCI. MRI measure infarct size was the same in both. All patients received aspirin, a P2Y12 inhibitor, and an anticoagulant. However, and this is a big however , 4 patients in the delayed group had

2018 Dr Smith's ECG Blog

91. A Very Elderly Male with a Fall and no Chest Pain

with Wellens' waves in V2 and V3. " My opinion was this : "There are no R-waves in V2 and V3, so it is not Wellens'. Furthermore, it can't be Wellens' syndrome even if the ECG is true Wellens' morphology: Wellens' syndrome requires that the ECG be recorded after an episode of chest pain that is now resolved. This patient had no pain at any time." I asked: "Is there a previous ECG for comparison?" (No, there was not) Continued "The QS-waves and shallow T-wave inversion are typical of a dense old transmural (...) have made me wonder whether there are q-vawes or not. Do you have any thoughts on how large the deflection would be to still call it a qs-complex? tom f very interesting, stephen GREAT case about a common primary care (as well as emergency care) issue! As per Dr. Smith, this ECG is not acute — but it most definitely suggests prior injury/infarction. In addition to lacking a history of chest pain — this tracing is not “Wellens Syndrome” because the infarction appears to have already taken place

2017 Dr Smith's ECG Blog

92. 12 Cases of Use of 3- and 4-variable formulas to differentiate normal STE from subtle LAD occlusion

involved). Case 7. A 60 year old male had resolving chest pain There is minimal ST elevation and there are subtle T-wave inversions in V2-V5 , highly suggestive of Wellens' 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) So this, along with the resolving chest pain , appears to be a reperfusing LAD occlusion. In Wellens' syndrome, the artery is open. T-wave inversion is indicative of reperfusion of the infarct-related vessel. BP was elevated, pulse lowered to 45. He received ASA, Plavix 600mg, Heparin, and a Nitro drip. Another ECG 15 minutes later, pain free, had more T-wave inversion. Then 15 minutes after that, the pain recurred and the T-waves pseudonormalized. The ST

2017 Dr Smith's ECG Blog

93. 2 Cases of Resolved Chest Pain with Dynamic Terminal T-wave Inversion

pattern. Since Wellens' syndrome is the pain-free aftermath of an episode of chest pain associated with LAD occlusion, then at the time of active pain at which time an ECG was recorded, the ECG should have shown some evidence of STEMI, or at least of subtle acute LAD occlusion. This first ECG is a normal variant ST elevation in a young male, with high voltage . It does not represent LAD occlusion. In such a case, one should not assume a benign etiology, but use serial troponins to verify that you (...) are correct. While it is true that, on rare occasion, Wellens' syndrome may have negative serial troponins, all such cases that I have seen were with earlier generation (less sensitive) troponins. Outcome : All troponins were below the level of detection up to 16 hours after presentation. Case 2: These ECGs are classic Wellens' pattern, but also with an unusual lead V2. I saw this patient and immediately knew the diagnosis. The initial troponin I was 1.2 ng/mL (99% URL is 0.030 ng/mL). He went very

2017 Dr Smith's ECG Blog

94. Do patients with LBBB and STEMI, when reperfused, develop T-wave inversion (reperfusion T-waves)?

. Smith SW . Validation of the Modified Sgarbossa Rule for Diagnosis of STEMI in the Presence of Left Bundle Branch Block. American Heart Journal 170(6):1255-1264; December 2015. Before the case, a few comments: Pendell and I just published a case report of a patient with left bundle branch block who presented with chest pain that then resolved. His ED ECG showed his baseline LBBB, with no evidence of MI. Over the ensuing hours, he developed classic T-wave inversion of Wellens' syndrome (...) , but in the context of LBBB! Troponins were then positive, and the angiogram revealed a 99% LAD lesion with thrombus. The case demonstrates that Wellens' syndrome can occur in the context of LBBB. Here is a link to the case report: Though Wellens' syndrome was described in the LAD territory, I have shown cases demonstrating that it occurs in any coronary distribution. That is to say, that reperfusion results in terminal T-wave inversion even if the involved territory is the inferior or the lateral wall. Today's

2017 Dr Smith's ECG Blog

95. How can you persuade your cardiologist to take a Non-STEMI patient to the cath lab emergently?

SR, Granger CB, Boden WE, et al. Early versus delayed invasive intervention in acute coronary syndromes. The New England journal of medicine 2009;360:2165-75. Posted by Steve Smith at Labels: , , Reactions: 16 comments: Hello. Great post thanks A question... Can we say that the leads v3 v4 v5 have de wellens waves suggesting LAD occlusion? Thanks. You mean de Winters, not de Wellens! de Winters waves look very similar to this and one could say they are an atypical version. Wellens waves are post (...) diffusely. This is diagnostic of ischemia. There is a Q-wave in V2 and a possible hyperacute T-wave. It is now clear the patient has acute coronary syndrome. It is not clear that there is, or is not, a complete coronary occlusion. The patient was treated with aspirin and sublingual NTG on arrival, which did not relieve his pain. Cardiology was called but they were not interested in taking the patient to the cath lab. First troponin I returned at 0.65 ng/mL. This confirms myocardial infarction. After

2017 Dr Smith's ECG Blog

96. Right precordial ST depression in a patient with chest pain

tall, peaked, anterior T waves, which we call "posterior reperfusion T-waves" or Wellens' syndrome of the posterior wall.(7) Authors in the past have confused acutely occluded posterior MI (which may have either upright or inverted T-waves) with, on the other hand, prolonged or reperfused posterior MI (both of which do indeed have upright T-waves). Is there a tall R-wave in right precordial leads in acute posterior STEMI? Similarly, a tall R-wave in V1 or V2 is not a feature of acute posterior (...) as ST elevation in lead V8: they are opposite! The magnitude may be different, but the direction should be opposite. If it is not, then the state of the artery may have changed. References 1. Wang T, Zhang M, Fu Y, et al. Incidence, distribution, and prognostic impact of occluded culprit arteries among patients with non–ST-elevation acute coronary syndromes undergoing diagnostic angiography Am Heart J 2009;157:716-23 2. Matetzky S, Friemark D, Feinberg MS, et al. Acute myocardial infarction

2017 Dr Smith's ECG Blog

97. Chest Pain Diagnosed as Gastroesophageal Reflux

inversion were indeed subtle Wellens' waves. In Wellens' original studies, every case had either an open artery (LAD) or collateral circulation. Wellens' waves imply reperfusion, but it might be due to collaterals, not due to reperfusion of the infarct-related artery. Learning Points 1. Beware ST depression 2. Never assume chest pain is reflux. They cannot be differentiated without troponin. (The ECG could be entirely normal in MI, though in this case it was NOT normal) 3. Wellens' syndrome is due (...) if his pain recurred. Another ECG was recorded at t = 46 minutes: There is less ST depression This was recorded at T = 105 minutes There is a suggestion of terminal T-wave inversion in V2, suggestive of Wellens' waves The next AM, this was recorded before the angiogram: What is the culprit artery? Here is the troponin profile: The angiogram showed a 100% thrombotic mid-LAD occlusion with faint left to right and right to left collaterals. Here is the post cath ECG: So that very subtle terminal T-wave

2017 Dr Smith's ECG Blog

98. Unusual ST Elevation in V1 and V2, and LVH, in a Patient with Chest Pain

and elevated troponins, only evolution of the ECG, or its absence, can establish the etiology of ECG findings that are questionable for ischemia. Other LVH PseusoSTEMI cases: This very important case posted a few days ago: posted just last week: Here is an extensive discussion of the LVH pseudoSTEMI phenomenon: PseudoWellens' due to LVH Wellens' waves are NOT equivalent to Wellens' syndrome: Pseudo-Wellens' due to LVH and HTN Posted by Steve Smith at Reactions: 10 comments: I would have thought about stemi (...) Pseudo-Wellens' due to LVH. They are recognizable. They do not rule out coronary occlusion but they leave room for careful evaluation, especially with high quality echocardiography. Often, even if you suspect PseudoSTEMI, angiogram may be the only way to be certain there is no acute coronary occlusion. However, if you are unaware of all the pseudoSTEMI patterns, you will pull the trigger on the cath lab too soon too often. In the context of an angiogram showing no obstructive coronary disease

2017 Dr Smith's ECG Blog

99. Is it important to recognize LVH Pseudo-infarction patterns?

about MI and asked to see me at the door to assess the ECG. What do you think? I looked at it and immediately said: "This is LVH. Not MI." And so we did not place the patient in the critical care area and did not activate the cath lab. What did I see? There is indeed ST elevation, but there is T-wave inversion also, and the TWI is in V4-V6. You might think it is Wellens', but Wellens' is a syndrome , not an ECG finding. It is a syndrome in which the pain has resolved (is gone). This patient's pain (...) was still present. Furthermore , a true Wellens' ECG has T-wave inversion in V2-V4, not just V4-V6. And it should not have high voltage. While Wellens' requires R-wave preservation in the affected leads, high voltage should make you think of what I call Pseudo- Wellens pattern due to LVH. Here is a true Wellens' case, showing evolution over time, in a patient whose pain had resolved: A. First ED ECG: T-wave inversion in V2 only, Pattern A (terminal T-wave inversion) B. At 2 hours, now V2-V4, Pattern

2017 Dr Smith's ECG Blog

100. 8 year-old with report of "syncope and an abnormal ECG".

, as the ECGs in this cohort all had T-wave inversion in V3-V6) is by far most common in African American males. Smith has studied all the EKGs in his cohort and found that: 1. There is a relatively short QT interval (QTc less than 425ms). 2. The leads with T-wave inversion often have very distinct J-waves . 3. The T-wave inversion is usually in leads V3-V6 (in contrast to Wellens' syndrome, in which they are V2-V4) 4. The T-wave inversion does not evolve and is generally stable over time (in contrast (...) to Wellens', ). 5. The leads with T-wave inversion (left precordial) usually have some ST elevation 6. Right precordial leads often have ST elevation typical of classic early repolarization 7. The T-wave inversion in leads V4-V6 is preceded by minimal S-waves 8. The T-wave inversion in leads V4-V6 is preceded by high R-wave amplitude 9. II, III, and aVF also frequently have T-wave inversion. Case Continued With respect to this specific case, the history was more consistent with a seizure: while

2017 Dr Smith's ECG Blog

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