Wellens Syndrome and other early EKG indications of badness =========================================================== þ Definition - Pattern of electrocardiographic T-wave changes present in mid-precordial leads (V2V3, usually in V4 as well) characterized by either (Type 1) deeply symmetric inverted T waves or (Type 2) biphasic T waves (Type 2 is the sneaky one, hard to pickup) and always needs stat cath - Type 2 is often misdiagnosed as "non-specific T-wave abnormality," (especially by automated EKG machines) but: - ECG abnormality is highly specific for critical obstruction in the proximal left anterior descending artery (LAD) High risk for extensive anterior MI and death þ Warnings... - ECG abnormality is not necessarily associated with ST changes - ECG abnormality is usually present when the patient is symptom-free - May be an incidental finding during an non-cardiac presentation or may be found on ECG after acute symptoms have resolved (patient is asymptomatic) - Cardiac biomarkers are often normal - *** Provocative testing, including stress imaging, may precipitate AMI - These patients are best evaluated with diagnostic catheterization rather then stress testing - Medical management is ineffective for proximal LAD lesions - Medical management may provide some initial symptomatic improvements, but natural history predicts anterior wall MI unless PCI is performed early - 75% of patients in Wellens' original description developed anterior wall MIs, usually within a few weeks of initial presentation if they were only treated medically! þ ECG criteria for Wellens' Syndrome - Tvpe 1: Symmetric and deeply inverted T-waves in leads V2 and V3, often in leads V1 and V4, occasionally in leads V5 and V6 OR - Type 2: Biphasic T-waves in leads V2 and V3, often in leads Vi and V4 PLUS - Isoelectric or minimally elevated ST segment - Absence of precordial Q-waves - Prior history of chest pain or anginal equivalent - ECG pattern is present in symptom-free state - Minimal or no elevation of cardiac biomarkers þ Loss of Precordial T-Wave Balance ("NTTV1": new tall T wave in V1) - The normal ECG shows progression of T-wave size across the precordium - The T-wave in lead Vi is normally flat or inverted - Occasionally is upright + In elderly patients, upright T-wave in Vi (TV1) is rarely a normal finding + Major exceptions — large upright TVi is a normal finding inpatients with LVH, HLVV, high voltage (young healthy people who are skinny) and LBBB - An upright TVi may indicate significant underlying atherosclerotic coronary artery disease + Manno, et al — upright TV1 is common in patients with significant atherosclerotic disease of the left circumflex artery and right coronary artery + Marriott — if the TV1 is larger than the TV6, suspect anterior and/or lateral myocardial disease (chronic or acute) - May be an early marker of impending MI - An new upright tall TVi (NTTVi) may be a marker of acute cardiac ischemia + Chung — upright TVi suggests acute cardiac ischemia + Smith — TVi > TVe suggests acute cardiac ischemia + Barthwal — TVi > TVs is associated with ischemic heart disease - 84% specific for ischemic heart disease - 16% false positives - The NTTVi may precede other expected ECG changes in acute ischemia - Be especially concerned when the upright TVi is new and large [Amal Mattu, ACEP 2008] þ Early Reciprocal Changes in Lead aVL - The normal ECG shows an isoelectric ST-segment and upright T-wave in aVL - An inverted T-wave in aVL is often found with inferior wall myocardial infarction + Represents a "reciprocal change" + Marriott — may precede the expected changes in inferior leads; may initially be the only abnormality found on the ECG of a patient with acute inferior MI or ischemia - Major exceptions — downsloping ST-segment and inverted T-wave in aVL is normal finding in patients with LVH and LBBB þ Lead aVR — "The Forgotten Twelfth Lead" - Acute occlusion of the left main coronary artery (LMCA) is fatal in > 70% of patients + Medical management (ASA, beta-blockers, heparin, even thrombolytics) does NOT improve outcome + PCI (and often CABG) must be performed to improve survival - Time delay to PCI is the only predictor of survival - These patients need immediate transfer for PCI! + Is it possible to identify which patients with ACS renuire immediate transfer based on the ECG? - ECG predictors of acute LMCA occlusion: + Simultaneous ST-segment elevation in leads aVR and aVL -> very highly specific specific for LMCA occlusion + Simultaneous ST-segment elevation in leads aVR and Vi -> highly specific for proximal LAD or LMCA occlusion, but... - ST-segment elevation in aVR >= V1: very highly specific for LMCA occlusion + ST-segment elevation in aVR >= 1.5 mm predicts 75% mortality (if not treated with immediate PCI) - Any of these findings predicts need for immediate PCI! þ Summary - Beware biphasic T-waves in the mid-precordial leads + These are not "non-specific!" + Highly specific marker for proximal LAD occlusions + Best managed with PCI - Beware the upright T-wave in lead Vi! + Especially if new + Especially if ^TV1 > TV6 + May be an marker of anterior ischemia or underlying CAD - Reciprocal changes in lead aVL may be the first sign of inferior wall myocardial ischemia + Observation and serial ECGs can increase the rate of detection of infarction - Don't forget about aVR! + STE in aVR with... - ST-segment elevation in aVL -> immediate PCI - ST-segment elevation in V1 -> immediate PCI Especially if STE in aVR > ^TE in V1 + ^ST in aVR > 1.5 mm -> 75% mortality if not treated with immediate PCI - Recognition of these subtle abnormalities will make the difference between life and eath! Don't rely on your cardiology consultants to make these diagnoses Emergency physicians must be the experts in electrocardiography! ==== Wellens' syndrome is a pattern of ECG T-wave changes associated with critical, proximal left anterior descending artery (LAD) lesion. Identification of Wellens' syndrome as these patients may be pain free at the time of the ECG changes, yet they are at very high risk of developing myocardial infarction. In addition, planning an exercise stress test for these patients can be fatal due to the severe stenosis that might lead to infarction at the time of increased cardiac demand. 1 Wellens' syndrome is not infrequent with a reported incidence of 10 to 15 percent in the United States 2 . In patients with this syndrome, the ECG is normal when done in periods with no chest pain, yet the T-wave abnormalities often appear after the disappearance of the chest pain. 3 In 1982 Wellens published his observation that a pattern of inverted T-wave in the precordial leads was strongly associated with early large anterior myocardial infarction and a poor prognosis in patients presenting with unstable angina. 2 He further demonstrated that most of these patients had severe stenosis of the proximal left anterior descending coronary artery and postulated that these patients would do better with early angiography and selective surgical treatment or angioplasty. Criteria: - prior chest pain - chest pain with normal EKG - normal or nearly-normal cardiac enzymes - no pathological Q waves or loss of R wave progression - ST segment in V2 and V3 that is isoelectric or minimally elevated (<1mm), concave or straight - Symmetric and deep T-wave inversion or biphasic T waves in V2 to V5 or V6 in pain-free periods - Tight proximal LAD stenosis The 2000 American College of Cardiology/American Heart Association guidelines for the management of patients with unstable angina pectoris include T-wave inversion greater than 0.2mV as a sign of ischemia. 5 However, in Wellens' syndrome the T-wave inversion despite of being nonspecific according these guidelines, in the right setting they are very predictive of a severe LAD lesion. Failure to diagnose Wellens' syndrome and thus not treating the underlying CAD can have a deleterious result. Typically, 75 % of these patients will develop anterior wall myocardial infarction, usually within a matter of days, even if they are treated with medical management. Consequently, early cardiac catheterization with subsequent angioplasty or coronary bypass surgery is now recommended for these patients. 4 The key features of this electrocardiographic syndrome are the T-wave findings. These changes may present in one of two patterns. In 75% of cases, the precordial T-waves are deeply inverted with symmetric contour. The less common variant, comprising 25% of cases presents with biphasic T-waves, as demonstrated in our case. Although in the classical cases of Wellens' syndrome the T-wave changes are evident only in pain-free periods and not during episodes of chest pain, our case represents a variation of Wellens' syndrome with the ECG changes persisting through the pain periods. Classically, in Wellens' syndrome, the inverted or biphasic T-waves are replaced during episodes of ischemia by positive T-waves with either ST-segment elevation or depression. 6 The origin of these T- wave changes remains unclear, but these changes can persist for months. After appropriate intervention these ECG abnormalities tend to normalize