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The electrocardiogram (ECG) on admission shows atrial fibrillation with slow ventricular response of 42 beats/min. In some QRS complexes, prominent biphasic T waves are seen in the precordial leads V1–V4 (Fig. 1). This Wellens’ ECG sign is suggestive of critical proximal left anterior descending (LAD) stenosis [1]. The electrocardiographic features are characterised by either biphasic T waves or the more common deep T‑wave inversion in the anteroseptal leads. Furthermore, precordial ST-segment deviation, pathological Q waves and poor R‑wave progression should be absent. These ominous T‑wave inversions mostly occur in patients with a history of angina in a pain-free period, whereas angina can cause “pseudonormalisation” of the T waves [2].
The arrows indicate the biphasic T waves in the precordial leads appearing after a preceding delay
Although the underlying mechanism remains elusive, it has been postulated that myocardial stunning due to oedema causes intramyocardial repolarisation inhomogeneity resulting in characteristic inversed or biphasic T waves [3]. Interestingly, the present ECG shows that the typical Wellens’ pattern only occurs after a long R‑R interval and thus a prolonged diastolic filling time, whereas rather short R‑R intervals are followed by normalised T waves. This phenomenon is presumably explained by the intermittent increase in left ventricular end-diastolic pressure impairing coronary perfusion and causing maximal ischaemia during contraction after a long R‑R interval with a large stroke volume.
In this patient, an emergent coronary angiogram indeed revealed a subtotal stenosis of the proximal LAD (Fig. 2). This lesion was successfully treated with the placement of a drug-eluting stent.
Coronary angiography revealing a subtotal stenosis in the proximal left anterior descending artery
This case underlines that early recognition and urgent revascularisation is imperative in patients with Wellens’ syndrome, as delay in intervention may lead to anterior myocardial infarction [1].
References
de Zwaan C, Bar 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;103:730–6.
Rhinehardt J, Brady WJ, Perron AD, Mattu A. Electrocardiographic manifestations of Wellens’ syndrome. Am J Emerg Med. 2002;20(7):638–43.
Migliore F, Zorzi A, Marra MP, et al. Myocardial edema underlies dynamic T‑wave inversion (Wellens’ ECG pattern) in patients with reversible left ventricular dysfunction. Heart Rhythm. 2011;8(10):1629–34. https://doi.org/10.1016/j.hrthm.2011.04.035.
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M. Kamali-Sadeghian, P.T.G. Bot, R. Tukkie, H.J. Wellens and D.J. van Doorn declare that they have no competing interests.
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Kamali-Sadeghian, M., Bot, P.T.G., Tukkie, R. et al. A peek behind the curtain. Neth Heart J 26, 469–470 (2018). https://doi.org/10.1007/s12471-018-1138-9
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DOI: https://doi.org/10.1007/s12471-018-1138-9