Clinical features

  There are deep, negative T waves in anterior leads.

  Observed during proximal Left Anterior Descending (
LAD) coronary artery occlusions.

      Clinically patients are diagnosed as
unstable angina pectoris.

  Unless LAD is intervened, negative T waves in precordial leads
may persist for hours to weeks.

  The patient
may or may not complain of chest pain at the time the ECG is recorded.



Clinical significance

  Correct diagnosis is very important to avoid impending anterior myocardial infarction.

 
Avoidance of treadmill exercise test and directly proceeding to coronary angiography

      may be the best strategy.




Diagnostic ECG criteria

  Negative T waves are most frequently observed in leads C2 and C3, and less frequently in leads C1-C4.

      Involvement of leads C1 to C6 is very rare.

  Two types of T wave negativity may be observed:

  1.
Deep and symmetrically negative T waves (3 times more frequent).

  2.
Biphasic T waves (less frequent type)

  ST segment elevation is either absent or less than 1 mm.

  Q waves are not observed.

  R wave progression in anterior leads is unaffected.




Differential diagnosis

  Extensive myocardial ischemia due to extensive coronary artery disease.

  Left ventricular hypertrophy (T wave changes usually involve leads I, aVL, C5 and C6).

  Intracerebral hemorrhage.

  Vasospasm due to cocain use or other causes (
pseudo-Wellens syndrome ).

  Persistent juvenile T pattern.




References

  Am Heart J 1982; 103: 730-736.

  Am Heart J 1989; 117: 657-665.

  Can J Cardiol 2008; 24: 404.

  American Journal of Emergency Medicine 2006; 24:122-129.

  Cardiol J. 2009;16(1):73-75.

  Isr Med Assoc J. 2003;5:129-130.

  Am J Emerg Med 2002; 20: 638-643.





ECG 1. The ECG above bleongs to a 78 years old woman who was hospitalized with the diagnosis of unstable angina pectoris.
The ECG is compatible with Wellens syndrome.

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Figure 1. Coronary arteriography was performed immediately.
LAD was totally occluded proximally .
The vessel going laterally to the right is the Circumflex (Cx) coronary artery .






ECG 2a. The ECG above belongs to 54 years-old man who came to the emergency room with the complaint of typical
retrosternal chest pain. A stent had been implanted to his right coronary artery 4 years ago. At that time, his LAD (Left Anterior
Descending coronary artery) was normal. The
ST segment depression observed in leads C3 to C5 suggests myocardial
ischemia. His cardiac enzyme levels (CK, CK-MB, troponin I) were normal.

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ECG 2b. Twelve hours later, the same patient's ECG shows
biphasic T waves in chest leads which suggest ( Type 2 Wellens'
syndrome
). His cardiac enzyme levels were not elevated. Wellens' syndrome pattern is one of the ECG abnormalities that may
be observed during the course of unstable angina pectoris. It cannot not be observed in all patients with LAD stenosis and
significant ischemia. Just twelve hours ago, this patient's ECG showed only ST segment depression.

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ECG 2c. The ECG above, belongs to the same patient and was recorded one year ago during a routine outpatient clinic
examination: normal ECG.

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Figure 2a. His coronary angiography was performed on the same day.
Anteroposterior cranial view showed
significant stenosis in proximal LAD
(left anterior descending artery).




Figure 2b. Right caudal oblique view also demonstrates the
significant stenosis
in LAD
. Right coronary arteriogram (not in this figure) showed that the stent in
RCA (right coronary artery) was patent.







ECG 3a. The ECG above belongs to a 77 years-old woman complaining of chest pain.

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ECG 3b. Her ECG was repeated next day. This time, negative T waves were observed in anterior leads: Wellens syndrome.
Anterior leads were recorded
at a calibration of 5mm/mV. She was referred to another hospital for coronary arteriography.

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ECG 3c. Her ECG immeadiately before coronary arteriography also showed negative T waves in anterior leads.

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Figure 3a. Her coronary angiography showed
significant stenoses of the the
proximal LAD (Left Anterior Descending coronary artery)
.
The
Cx (circumflex coronary artery) and its branch Obtus Marginal were normal.



Figure 3b.
Insignificant stenoses of RCA (Right Coronary Artery) was observed.





ECG 4. The ECG above was recorded during the late outpatient visit of a 60 years-old man who had an acute anterior
myocardial infarction one month ago. This ECG DOES NOT show Wellens syndrome.
Absence of normal R wave progression
in anterior leads
and the presence of QS waves in leads V1 and V2 are signs of OLD ANTERIOR MYOCARDIAL INFARCTION.

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