don’t miss this diagnosis

19 Mar

RAGING HYPOTHETICAL:

A 45 year old man presents with progressively worsening chest pain over the past 2 days. The pain is a dull pressure in his left chest, associated with exertion which lasts for 10-20 minutes at a time. It is relieved with rest and antacids.

He had an episode this morning (10 hours ago) and was convinced to come to the hospital by his wife and is currently pain free. He has a history of hypertension and diabetes and he is a long time smoker.
 
Physical exam is unrevealing. Lab work including serial troponin is negative. EKG (shown below) shows no ST segment elevation.
 
File:Wellens' Syndrome.png
 
Discharge with cards follow up and stress testing?
Your patient goes home to die because you have failed to diagnose…WELLENS’ SYNDROME
 
EKG Criteria
 
  • Biphasic T waves in V2 and V3 (pictured below on left) OR deep symmetrical T waves in V2 and V3 and sometimes in other precordial leads as well (pictured below on right)
  • No pathologic Q waves in precordial leads
  • Little to no ST elevation in precordial leads
  • No loss of precordial R waves

Common Findings:

  • Prior history of chest pain
  • Little to no troponin elevation
 wellensgraphic
 
Additional Key Points:
 
specific for critical LAD stenosis
 
For those averse to eponymous syndromes, this is also known as Left Anterior Descending T Wave Syndrome
 
In the ER doctor’s mind, these patients should be distinct from similar patients presenting with anginal symptoms and negative biomarkers in which population outpatient stress testing is a reasonable disposition
 
These patients should not receive a cardiac stress test as this may precipitate acute MI
 
These patients should receive cardiology consultation in the ED with likely admission and cardiac catheterization
 
Submitted by L. Cunningham.

References: Wellens’ Syndrome. TK Tandy, DP Bottomy, JG Lewis – Annals of emergency medicine, 1999. Online.; 

Electrocardiograms You Need to Know: Wellens’ Syndrome. Roberts, James R. MD. Emergency Medicine News: August 2009 – Volume 31 – Issue 8 – pp 12-14;
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