Wellens' syndrome

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Synonyms and keywords: Wellen's syndrome; Wellen's Ts; Wellen's T waves; Wellen's sign; Wellens' Ts; Wellens' T waves; Wellens' sign; Wellen syndrome; Wellen Ts; Wellen T waves; Wellen sign

Overview

Wellens' syndrome (or sign, or occasionally warning) is an electrocardiographic manifestation of critical proximal left anterior descending (LAD) coronary artery stenosis in patients with unstable angina. It is characterized by symmetrical, often deep >2mm, T wave inversions in the anterior precordial leads. A less common variant is biphasic T wave inversions in the same leads.

Historical Perspective

The syndrome was first described by Hein J. J. Wellens and colleagues in 1982 in a subgroup of patients with unstable angina.

Causes

Wellens' syndrome is associated with atherothrombotic occlusion of the left anterior descending artery. Wellens' sign has also been seen as a rare presentation of Takotsubo or stress cardiomyopathy.

Epidemiology and Demographics

The syndrome is present in 16% of patients in the orginal description and in 14% of patients at presentation in a prospective study and in 60% of patients within the first 24 hours.

Natural History, Prognosis and Complications

The presence of Wellens' syndrome carries significant diagnostic and prognostic value. All patients in the De Zwann's study with characteristic findings had more than 50% stenosis of the left anterior descending artery (mean=85% stenosis) with complete or near-complete occlusion in 59%. In the original Wellens' study group 75% of those with the typical syndrome manifestations had an anterior myocardial infarction. Sensitivity and specificity for significant (more or equal to 70%) stenosis of the LAD artery was found to be 69% and 89% respectively with positive predictive value 86%.

Diagnosis

Electrocardiographic Criteria

• Progressive symmetrical deep T wave inversion in leads V₂ and V₃
• The slope of the inverted T waves is generally at 60°-90°
• There is little or no cardiac marker elevation
• There is discrete or there is no ST segment elevation
• There is no loss of precordial R waves

Electrocardiographic Examples

Shown above is the EKG of a 69-year-old black male with Wellens' sign.

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Coronary angiogram showing tight, critical stenosis (95%) of the proximal LAD in a patient with Wellens' Warning

Shown above is a coronary angiogram showing a tight, critical stenosis in the proximal left anterior descending coronary artery (left); After placement of a bare-metal stent (right). Wellens' warning.

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Shown above is the EKG of a patient with Wellens' sign during an episode of chest pain.

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Shown above is the EKG of the same patient after the episode of chest pain had resolved. Despite resolution of the chest pain, note the persistent biphasic T waves in leads V₂ and V₃.