Recognizing Wellens Syndrome in a Family Practice Setting

Case Report

J Fam Med. 2023; 10(4): 1338.

Recognizing Wellens Syndrome in a Family Practice Setting

Soliman M*; Voelckers A

Department of Family Medicine, University of Pittsburgh Medical Center Lititz, USA

*Corresponding author: Soliman M Department of Family Medicine, University of Pittsburgh Medical Center Lititz, 1500 Highlands Dr, Lititz, PA, 17543, USA. Tel: 717-824-2405; Fax: 717-291-8544 Email: [email protected]

Received: September 27, 2023 Accepted: October 20, 2023 Published: October 27, 2023

Abstract

Wellens syndrome is an Electrocardiographic (ECG) pattern that is associated critical stenosis of the Left Anterior Descending (LAD) artery. It manifests as either biphasic T waves in V2-V3 (type A) or deeply negative T waves in V2-V4 (type B). These T-wave abnormalities are persistent and can endure for hours to weeks. Patients with Wellens syndrome often lack chest pain and typically display normal or slightly elevated cardiac enzyme levels. It is critical for clinicians working in both outpatient and inpatient clinical settings to understand and recognize these ECG changes and its association with critical LAD obstruction and significant risk of anterior wall myocardial infarction.

In this case report, we present a unique case of Wellens syndrome type B in an asymptomatic 83-year-old male patient initially assessed and evaluated in an outpatient family practice clinical setting.

Keywords: Wellens syndrome; Left anterior descending artery; LAD Stenosis; Electrocardiography (ecg); Cardiology; ECG abnormalities

Introduction

Wellens syndrome is a pre-infarction stage of coronary artery disease. It is commonly found in patients with total or near total occlusion of the proximal left anterior LAD [1-3]. Patients with Wellens syndrome often present to the Emergency Department (ED) pain-free and usually with normal or slightly elevated cardiac enzymes [1-2]. However, it is important to recognize Wellens syndrome ECG patterns as patients can quickly deteriorate due to their high risk for large anterior wall acute myocardial infarction [1-3]. Wellens syndrome describes a pattern of ECG changes which is highly specific for critical, proximal stenosis of the LAD.

The clinical and ECG criteria for Wellens syndrome are as follows [1-2]:

• Type A Wellens syndrome – biphasic T waves (with initial positivity and terminal negativity) in V2 and V3 [1]

OR

PLUS

• Isoelectric or minimally elevated ST segment, less than 1 mm (in other words, no signs of an acute anterior wall myocardial infarction)

• Preservation of precordial R-wave progression AND no precordial Q waves (in other words, no signs of old anterior wall infarct)

• Recent history of angina

• ECG patterns present in a pain-free state

• Normal or slightly elevated cardiac markers

Drs. De Zwann, Wellens, and colleagues were first to identify the syndrome in the early 1980’s; in their discoveries, it was noted that 75% of patients with Wellens syndrome ECG findings went on to develop an acute anterior wall myocardial infarction within weeks if only treated with medical management [4-5]. Definitive treatment typically involved cardiac catheterization with Percutaneous Coronary Intervention (PCI) to relieve the occlusion [1-3,5-6]. We present a case of Wellens syndrome type B in an asymptomatic 83-year-old male patient who was initially evaluated in an outpatient family practice clinical setting.

Case Presentation

An 83-year-old male presented at an outpatient family practice clinic with a complaint of intermittent dizziness ongoing for about 1 year, with a noticeable worsening in the last 1 to 2 months. The patient has a past medical history of type 2 diabetes mellitus, hypertension, hyperlipidemia, and stage 3A chronic kidney disease. The dizziness appears to only be triggered when transitioning from lying to seated positions. Patient denies chest pain or tightness, palpitations, diaphoresis, shortness of breath, or syncope.

On physical examination, the patient was afebrile with a heart rate of 55, blood pressure of 118/78, respiratory rate of 18, and oxygen saturation of 98% in room air. Physical exam performed in clinic was notable for grade 3/6 systolic murmur and 1+ lower extremity edema bilaterally. Cranial nerves II-XII were intact, with no observable focal neural deficits. The point-of-care ECG revealed sinus bradycardia with a heart rate of 51 and a right bundle branch block as well as T-wave inversion in leads V2-V4 (Figure 1). These findings prompted the decision to transfer the patient to an emergency department for a comprehensive cardiac evaluation.

Citation:Soliman M, Voelckers A. Recognizing Wellens Syndrome in a Family Practice Setting. J Fam Med. 2023; 10(4): 1338.