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Wellens’ Syndrome - the ″widow maker″

Poster · April 2020

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 Wellens’ Syndrome - the ″widow maker″

Adnan Nozic1, Virginie Tachinni2, Georgios Tzimas 2, Olivier Lamy1

1 Departement of Internal Medicine, Lausanne University Hospital, Switzerland

2 Departement of Cardiology, Lausanne University Hospital, Switzerland

CASE

A 38-year-old man was admitted to the emergency department complaining of intermittent chest pain of several weeks’ duration, suggestive of typical angina. At the
presentation he was pain free, and his vital signs and cardiovascular examination were normal. An ECG showed biphasic T wave in leads V2 through V4 and inverted T
wave in leads aVL and V1 with minimal ST elevation in leads V1 through V3 (Figure 1). The high-sensitive troponin T level was normal. He was diagnosed with
unstable angina and was admitted to the cardiology ward. A coronary angiography revealed severe stenosis in the proximal left anterior descending (LAD) coronary
artery. (Figure 2). The patient underwent proximal LAD angioplasty with a 2 drug-eluted stents and he was discharged 3 days later with normalization of the ECG.

Figure 2. Coronarography showing severe LAD stenosis (red arrow).

 Type A: Symmetric & deeply inverted T waves

in V2-V3.
 Type B: Biphasic T waves in V2-V3.
 No precordial Q waves or loss of precordial
R-wave progression.
 Minimal (<1mm) ST segment elevation.
Figure 3. Diagnostic ECG criteria for Wellens’ syndrome.
Figure 1. ECG showing biphasic T wave in leads V2-V4, T wave inversion in leads V1 et aVL.

DISCUSSION

This specific ECG pattern, also known as the Wellens’ syndrome, is associated with a critical stenosis or obstruction of the proximal LAD, with a sensitivity of 69%
and specificity 89%. Since the LAD supplies the anterior wall of the heart, an occlusion in this vessel results in an extensive anterior wall myocardial infarction
causing serious ventricular dysfunction, thus placing the patient at risk of cardiogenic shock, fatal arrythmias and death. Wellens’ syndrome is classified into type A
or type B. Type A is defined by symmetric deeply inverted T waves, whereas type B is defined by biphasic T waves (Figure 4). In both types, these ECG changes are
most prominent in leads V2 and V3, but can also involve any of the precordial leads. Notably, Wellens’ syndrome patients lack Q waves, loss of precordial R-wave
progression or significant changes of ST segment. The criteria used to diagnose Wellens’ syndrome are summarized in Figure 3. The diagnosis is difficult as most
patients with Wellens' syndrome don’t have chest pain on presentation, the cardiac enzymes are normal or slightly elevated and frequently the ECG findings are
interpreted as nonspecific repolarization changes. Thus, this syndrome is frequently under-recognised and has fatal consequences; it is, therefore, also known as the
“widow maker”. Prompt recognition of this ECG pattern is crucial for every physician or paramedic dealing with acute coronary syndrome, as misinterpretation of
those high risk presentations can lead to reperfusion delays and worse outcomes.

LEARNING OBJECTIVES / CONCLUSION

Wellens’ syndrome is associated with a critical stenosis or obstruction of the proximal LAD carrying a life-threatening
prognosis if not recognized promptly. In the presence of this ECG pattern, maintaining a high index of clinical suspicion
and early involvement of interventional cardiologists in the decision process is of paramount importance.
Figure 4. Type A and type B Wellens’ syndrome.

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