Wellens syndrome

Introduction

Wellens syndrome (´´widowmaker´´, ´´LAD coronary syndrome´´) is a pattern of T wave abnormalities in precordial leads, which is highly associated with a critical stenosis of the left anterior descending artery (LAD). 

Its natural progression leads to anterior wall MI within the next few days or weeks. This progression is rapid, so it is very important to recognise this pattern early. 

ECG manifestation 

  • Characteristic T-wave changes (symmetric and deeply inverted T waves or biphasic T waves in leads V2 and V3) in a pain free state
  • Recent history of AP
  • Normal or slightly elevated cardiac markers
  • Absence of precordial Q waves, isoelectric or minimal (< 1mm) ST elevation, and normal precordial R wave progression

There are two patterns of T-wave abnormality in Wellens syndrome:

  • Type A – Biphasic, with initial positivity and terminal negativity 
  • Type B – Deeply and symmetrically inverted 

T wave changes can evolve over time from Type A to Type B pattern

Management

  • coronary angiography/PCI
  • UFH
  • ASA
  • P2Y12 inhibitors
  • nitrates
  • 02

ECG 1 Wellens sign - biphasic T waves in V2-V4 leads in a patient with  a critical stenosis of LAD

References

  1. Benjamin B Mattingly, Kevin M Gentile, Erik D Schraga. Wellens Syndrome: Background, Pathophysiology, Etiology. Diseases & Conditions - Medscape Reference [online]. https://emedicine.medscape.com/article/1512230-overview
  2. de Zwaan C, Bär FW, Wellens HJ. Characteristic electrocardiographic pattern indicating a critical stenosis high in left anterior descending coronary artery in patients admitted because of impending myocardial infarction.Am Heart J. 1982; 103:730–736. doi: 10.1016/0002-8703(82)90480-x
  3. Al-Assaf O, Abdulghani M, Musa A, AlJallaf M. Wellen's Syndrome: The Life-Threatening Diagnosis. Circulation. 2019 Nov 26;140(22):1851-1852. doi: 10.1161/CIRCULATIONAHA.119.043780. Epub 2019 Nov 25. PMID: 31765255.
  4. Tandy TK, Bottomy DP, Lewis JG. Wellens syndrome. Ann Emerg Med. 1999 Mar;33(3):347-51.
  5. https://litfl.com/wellens-syndrome-ecg-library/