Wellens Syndrome

Mike Cadogan and Robert Buttner ●

Sep 8, 2021

HOME ECG LIBRARY

Wellens Syndrome is a clinical syndrome

characterised by biphasic or deeply
inverted T waves in V2-3, plus a history
of recent chest pain now resolved. It is
highly specific for critical stenosis of the
left anterior descending artery (LAD)

Wellens pattern A:
Biphasic T waves

Wellens pattern B: Deeply

inverted T waves

The pattern is usually present in the pain free

state — it may be obscured during episodes of
ischaemic chest pain, when there is
“pseudonormalisation” of T waves in V2-3
Wellens syndrome is a key example of why all
patients presenting with chest pain must have
serial ECGs

Clinical significance
Patients may be pain free by the time the ECG
is taken, and have normal or minimally elevated
cardiac enzymes. However, they are at
extremely high risk for extensive anterior wall
MI within the subsequent days to weeks
Due to the critical LAD stenosis, these patients
usually require invasive therapy, do poorly with
medical management, and may suffer MI or
cardiac arrest if inappropriately stress tested

Diagnostic criteria

Rhinehart et al (2002) describe the following

diagnostic criteria for Wellens syndrome:

Deeply inverted or biphasic T waves in

V2-3 (may extend to V1-6)
ECG pattern present in pain-free state
Isoelectric or minimally-elevated ST
segment (< 1mm)
No precordial Q waves
Preserved precordial R wave progression
Recent history of angina
Normal or slightly elevated serum
cardiac markers

There are two patterns of T-wave abnormality in

Wellens syndrome:

Type A – Biphasic, with initial positivity and

terminal negativity (25% of cases)
Type B – Deeply and symmetrically inverted
(75% of cases)

Biphasic T Waves (Type A)

Wellens Pattern A (Type 1)

Wellens Pattern A (Type 1)

Deeply Inverted T Waves (Type B)

Wellens Pattern B (Type 2)

Wellens Pattern B (Type 2)

Wellens T wave evolution

T wave changes can evolve over time from Type A

to Type B pattern (Smith et al).

Evolution of T-wave inversion [A-D] after coronary

reperfusion in STEMI reperfusion and in Wellens
syndrome (NSTEMI). Modified from Smith et al.
Evolution of T-wave inversion. The ECG in acute MI,
2002

Understanding T wave changes

The following sequence of events is thought to

occur in patients with Wellens syndrome:

A sudden complete occlusion of the LAD

causes a transient anterior STEMI, causing
chest pain & diaphoresis. This stage may not
be successfully captured on an ECG recording
Re-perfusion of the LAD (e.g. due to
spontaneous clot lysis or prehospital aspirin)
leads to resolution of chest pain. ST elevation
improves and T waves become biphasic or
inverted. The T wave morphology is identical
to patients who reperfuse after a successful
PCI
If the artery remains open, the T waves evolve
over time from biphasic to deeply inverted
The coronary perfusion is unstable, however,
and the LAD can re-occlude at any time. If this
happens, the first sign on the ECG is an
apparent normalisation of the T waves —
so-called “pseudo-normalisation”. The T
waves switch from biphasic/inverted to upright
and prominent. This is a sign of hyperacute
STEMI and is usually accompanied by
recurrence of chest pain, although the ECG
changes can precede the symptoms
If the artery remains occluded, the patient now
develops an evolving anterior STEMI
Alternatively, a “stuttering” pattern may
develop, with intermittent reperfusion and re-
occlusion. This would manifest as alternating
ECGs demonstrating Wellens and
pseudonormalisation/STEMI patterns

This sequence of events is not limited to the

anterior leads — similar changes may be seen in
the inferior or lateral leads, e.g. with RCA or
circumflex occlusion.

Also, the inciting event does not necessarily have

to be thrombus formation — Wellens syndrome
may also occur in normal coronary arteries
following an episode of vasospasm, as in this case
of cocaine-induced vasospasm. However, it is
safer to assume the worst (i.e. critical LAD
stenosis) and work the patient up for an
angiogram.

The concept of occlusion/reperfusion/re-

occlusion is explained by Dr Stephen Smith. Also
check out Example 5, below.

History of Wellens Syndrome

1979 – Gerson et al first described the

occurrence of exercise-induced U wave inversion
(inverted terminal T-waves) in the precordial leads
in patients with proximal left anterior descending
artery (LAD) ischemia. 33/36 patients (92%) with
this abnormality had >75% stenosis in the
proximal LAD.

1980 – Gerson further evaluated ‘U-wave

inversion‘, this time at rest, and found 24/27
(89%) of patients with the ECG findings had
evidence of LAD or left main ischemia.

1982 – De Zwaan, Wellens et al reported a similar

ECG abnormality without mentioning inverted U-
waves. They observed that patients admitted for
unstable angina with this ECG finding were at high
risk for myocardial infarction.

Semantic nomenclature

There is confusion in the literature regarding the

naming of the T wave patterns, with some authors
using Type 1 (Type A) for biphasic T waves and
Type 2 (Type B) for inverted. It may be better to
just describe the T wave pattern!

Original description**

ECG patterns in precordial leads of the patients

reported. Pattern A was found in four patients;
pattern B, in 22 patients

Classification of Wellens ECG patterns: 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

Example ECGs

Example 1

Wellens Syndrome (Type A Pattern)

Biphasic precordial T waves with terminal

negativity, most prominent in V2-3
Minor precordial ST elevation
Preserved R wave progression (R wave in V3 >
3mm)

Example 2

Wellens Syndrome (Type A Pattern)

The biphasic T waves in V2-3 are

characteristic of Wellens syndrome

Example 3

Wellens Syndrome (Type B Pattern)

There are deep, symmetrical T wave inversions

throughout the anterolateral leads (V1-6, I,
aVL)

Example 4

Wellens Syndrome (Type A Pattern)

Biphasic T waves with minimal ST elevation in

V1-5, consistent with Wellens syndrome
The patient had experienced ischaemic chest
pain immediately prior to arrival in hospital and
was pain free at the time the ECG was taken

The prehospital ECG from ~15 minutes earlier

demonstrates a clear anterolateral STEMI:

This prehospital ECG was taken while the

patient was still symptomatic with chest pain
and diaphoresis
It shows unmistakable features of anterolateral
STEMI, with marked precordial ST elevations
and inferior reciprocal change
The symptom resolution and conversion to a
Wellens ECG on arrival to hospital indicates
reperfusion of the LAD

Example 5

This fantastic ECG series (submitted by

paramedic Andrew Bishop) shows a stuttering
pattern of LAD occlusion, reperfusion and re-
occlusion in a middle aged lady with chest pain.

The ECGs are presented in chronological order,

over a 45 minute period from the prehospital
environment to the cath lab:

(a) Patient experiencing chest pain and

diaphoresis

The ECG shows a clear anterolateral STEMI,

with inferior reciprocal change
The artery is occluded at this point

(b) Resolution of pain

The ECG now shows a typical Wellens pattern

of biphasic T waves in V2-3, plus improvement
in the anterolateral ST elevation
This indicates spontaneous reperfusion of the
LAD — i.e. the artery has re-opened

(c) Recurrence of chest pain and diaphoresis

With recurrence of pain there is pseudo-

normalisation of the precordial T waves: the
previously biphasic T waves have become
prominently upright (= “hyperacute” T waves)
This apparent normalisation of the T waves
indicates re-occlusion of the LAD artery

(d) Ongoing ischaemic symptoms

Following re-occlusion of the artery, there is

further evolution of the anterolateral ST
changes, with evolving anterior STEMI

(e) Symptoms improving

Once again there is reperfusion of the artery,

only this time the ST changes are slower to
resolve

(f) Now Pain Free

Now the T waves are starting to become

biphasic again (Wellens Pattern A)

Shortly after this series of ECGs was taken, this

patient suffered a VF arrest that was refractory to
defibrillation. She was placed on a mechanical
CPR device and taken to the cath lab, where she
was found to have a 100% proximal LAD stenosis.
This was stented, she was successfully
cardioverted and subsequently made a good
neurological recovery!

Differential Diagnosis of Wellens

Syndrome

While the morphology of the T wave changes in

Wellens syndrome is often quite distinctive, there
are numerous other conditions that may produce
similar patterns of precordial T-wave inversion,
including:

Pulmonary embolism
Right bundle branch block
Right ventricular hypertrophy
Left ventricular hypertrophy
Hypertrophic cardiomyopathy
Raised intracranial pressure
Normal paediatric ECG
Persistent juvenile T wave pattern
Brugada syndrome
Hypokalaemia

Explore the links above to appreciate the

similarities and differences between these ECG
patterns.

But is this Wellens?

This ECG was initially posted as an example of

Wellens syndrome. What do you make of it?

Reveal Answer

What about this example?

Reveal Answer

Learn from the Experts!

Consolidate your learning with lessons from the

masters of ECG interpretation. Follow the links
below for expert commentary, video lessons,
case-based discussion and detailed explanations
to take your learning to the next level.

Dr Smith’s ECG Blog – Wellens Syndrome

(case discussions)
Dr Smith’s ECG Blog – Wellens Mimics (case
discussions)

Related Topics

Anterior STEMI
De Winter’s T waves
ST elevation in aVR — a sign of LMCA
occlusion?
Myocardial ischemia
“Pain free and in VT?” – an ECG Exigency
ECG Case 132

References
GersonMC, Phillips JF, Morris SN, McHenryPL.
Exercise-induced U-wave inversion as a
marker of stenosis of the left anterior
descending coronary artery. Circulation
1979;60:1014–1020
Gerson MC, McHenry PL. Resting U wave
inversion as a marker of stenosis of the left
anterior descending coronary artery. Am J
Med 1980;69:545–550
de Zwaan C, Bär FW, Wellens HJ.
Characteristic electrocardiographic pattern
Find indicating
out more a- Download free high in left anterior
critical stenosis
reference card
descending coronary artery in patients OPEN
Reference card: the go-to document that helps you
identify patient-ventilator asynchronies hamilton-
admitted because of impending myocardial
medical.com