A new pattern of Wellens syndrome ?

Introduction: Wellens syndrome typically descri-bes the repolarization changes in the anterior territory – biphasic T waves (or negative/deep T waves) in V2-V4; this ECG appearance is highly suggestive for critical coronary lesion on proximal interventricular artery (IVA/LAD). These patients have a high risk of developing myocardial infarction in the coming weeks (~75% according to literature data) if they are only me-dical treatment. ECG alterations are therefore equiva-lent to a pre-infarcted status, with LAD subocclusion (or temporary complete obstruction by rupture of un-stable plaque or vasospasm, followed by reperfusion). Wellens, De Zwaan and colleagues describe (in 1982) 2 types of ECG changes: type A – with biphasic T waves in V2-V3/4 (25% of cases) and type B – with negative T waves in V2-V5 (75% of cases); often biphasic T-waves become deeply negative in the next hours/days. Litera-ture data describes Wellens-like modifications also in the posterior or lateral territory. But the changes in the inferior leads also correlate with severe coronary lesi-ons?

Methods: We present the case of a 77-year-old hyper-tensive, dyslipidemic woman with recent non-ST seg-ment elevation myocardial infarction (2 weeks ago) who transfered to us from another center for coronaro-graphy. Biphasic T waves in DIII, aVF and T-biphasic T in V3-V4 are noted on ECG (out of pain).

Results: T he coronary angiography reveals proximal right coronary artery subocclusion and severe stenosis in segment I-II of anterior interventricular artery (IVA/ LAD). Coronary angioplasty is performed by implan-ting one DES stent at each lesion. After myocardial re-vascularization, the ECG reveals deep-negative T-wa-ves in DIII, aVF and biphasic T in V2-V5. The electri-cal substrate and explanations are similar with Wellens syndrome, and the prognosis seems to be the same – the progression to a major acute myocardial infarction in the near future.

Conclusions: The case above describes ECG changes similar to those described by Wellens, but in the inferi-or territory, and the angiographically identified lesion is corresponding as severity – proximal subocclusion of the right coronary artery (versus the LAD proxi-mal subocclusion in Wellens classical description). Thus, this possible novel pattern of Wellen’s syndrome suggests that biphasic (or deep negative) T waves loca-ted on inferior leads may have the same pathological significance than classical ones.

ISSN – online: 2734 – 6382
ISSN-L 1220-658X
ISSN – print: 1220-658X
The Romanian Journal of Cardiology is indexed by:
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CODE: 379
CME Credits: 10 (Romanian College of Physicians)