ECGs - Things not to miss



A 52 years old patient with well controlled diabetes mellitus came to see his family doctor on a Sunday morning. He has developed a mild chest pain last night which lasted only for a few minutes. Pain was central, without any radiation or autonomic features. However, he had experienced a similar pain about a month back when he was running to catch a train.

At the time of consultation there was no pain whatsoever.

An ECG was taken.

Image result for ecg wellen syndrome

In view of the mild T inversions, the GP asked to check a troponin level, which was normal. He started the patient on Aspirin and increased his usual atorvastatin dose to 40mg. He also prescribed sublingual GTN to be used SOS.

If you were the GP, what would you have done?



This is Wellens syndrome!
What is it?

 It is a characteristic ECG pattern which indicates critical stenosis of the proximal Left Anterior Descending artery.
What would happen if you miss it?

 Unless proper intervention is done, it will progress into a anterior ST elevation MI.
Soon?

 Yes, in most within days. About 60% will develop STEMI within a week.
What are the features?

 There are 'types'.  But the type does not really matter.

 Features to look for are,

  • Deep symmetrical T inversions in V1- V4. Sometimes it may extend to V5 V6 as well.
  • Biphasic T waves in V2-V3 (ECG of our patient).


 ECG demonstrating the second type of pattern associated with Wellens’ syndrome


 What to do if the patient has no chest pain?

 These ECG features are typically seen when the patient is PAIN FREE. Changes might disappear during the anginal episodes.

So what should I do if I see this?

 Manage as unstable angina. Send the patient to a cardiologist as early as possible.
Are all anterior T inversions err.. Wellens?

 NO. Many conditions can give rise to 'Wellens' pattern. You better read!
Related image


Dr. Hein Wellens. Some consider him to be the founding father of cardiac electrophysiology.

 https://www.kardiologie.org/ekg/the-ecg-in-emergency-decision-making/15316636

This is him lecturing in his early eighties. If you are really interested spare an hour to listen to this. You won't regret!



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