Abstract

Wellens syndrome is a distinct electrocardiographic (ECG) finding that reflects critical narrowing of the proximal left anterior descending (LAD) coronary artery. First identified in 1982, this pattern typically appears in patients with a history of unstable angina, especially during pain-free intervals. Recognizing this syndrome is vital, as it signals a high risk for imminent anterior wall myocardial infarction if not treated promptly. The syndrome is classified into two types based on T wave morphology. Type A, which features biphasic T waves most prominently in leads V2 and V3, can be particularly challenging to identify. These subtle ECG changes are often overlooked, especially when the patient is not actively experiencing chest pain, which increases the risk of misdiagnosis or delayed treatment. Such oversight can lead to rapid deterioration and serious cardiac complications, including extensive myocardial infarction. In this case report, we present a patient with type A Wellens syndrome, where the early ECG showed only mild biphasic T wave abnormalities that were initially missed. This diagnostic oversight delayed appropriate cardiologic intervention and emphasized the importance of vigilance in evaluating atypical or transient ECG changes. Early identification of Wellens syndrome, even in asymptomatic phases, is critical to guiding appropriate management and preventing life-threatening outcomes. Clinicians, particularly in emergency medicine settings, should be aware of these subtle yet significant ECG markers.

• 1.   de Zwaan C., Bär FWHM, Wellens HJJ. 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(4): 730–6. https://doi.org/10.1016/00028703(82)90480-X
• 2.   Tandy T.K., Bottomy D.P., Lewis J.G. Wellens’ syndrome. Ann Emerg Med. 1999; 33(3): 347–51. https://doi.org/10.1016/S01960644(99)70373-2
• 3.   de Zwaan C., Bär FW, Janssen JHA, Cheriex E.C., Dassen WRM, Brugada P., et al. Angiographic and clinical characteristics of patients with unstable angina showing an ECG pattern indicating critical narrowing of the proximal LAD coronary artery. Am Heart J. 1989; 117(3): 657–65. https://doi.org/10.1016/0002-8703(89)90742-4.
• 4.   Kobayashi A., Misumida N., Kanei Y., Fox J. CRT-111 prevalence and prognostic value of Wellens’ sign in patients with non-ST elevation myocardial infarction. JACC Cardiovasc Interv. 2015; 8(2 Suppl): S11–2. https://doi.org/10.1016/j.jcin.2014.12.041
• 5.   Rhinehardt J., Brady W.J., Perron A.D., Mattu A. Electrocardiographic manifestations of Wellens’ syndrome. Am J Emerg Med. 2002; 20(7): 638–43. https://doi.org/10.1053/ajem.2002.34800
• 6.   Oo SZMWH, Khalighi K., Kodali A., May C., Aung T.T., Snyder R. Ominous T-wave inversions: Wellens’ syndrome revisited. J Community Hosp Intern Med Perspect. 2016; 6(4). https://doi.org/10.3402/jchimp.v6.32011
• 7.   Grautoff S. Wellens’ syndrome can indicate high-grade LAD stenosis in case of left bundle branch block. Herzschrittmacherther Elektrophysiol. 2017; 28(1): 57–9. https://doi.org/10.1007/s00399-017-0489-z
• 8.   Hsu Y.C., Hsu C.W., Chen T.C. Type B. Wellens’ syndrome: electrocardiogram patterns that clinicians should be aware of. Tzu Chi Med J. 2017; 29(2): 127–8. https://doi.org/10.4103/tcmj.tcmj_26_17
• 9.   Sedhai Y.R., Pawar A.S., Bhattacharya P.T., Basnyat S. Wellens’ syndrome, a case report of an electrocardiographic warning sign. J Adv Intern Med. 2017; 5(1): 19–23. https://doi.org/10.3126/jaim.v5i1.17067
• 10.   Inayat F., Riaz I., Ali N.S., Figueredo V.M. Pseudo-Wellens’ syndrome secondary to concurrent cannabis and phencyclidine intoxication. BMJ Case Rep. 2018. https://doi. org/10.1136/bcr-2018-225755
• 11.   Migliore F., Zorzi A., Perazzolo Marra M., Iliceto S., Corrado D. Myocardial edema as a substrate of electrocardiographic abnormalities and life-threatening arrhythmias in reversible ventricular dysfunction of Takotsubo cardiomyopathy: imaging evidence, presumed mechanisms, and implications for therapy. Heart Rhythm. 2015; 12(8): 1867–77. https:/doi.org/10.1016/j.hrthm.2015.04.041

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