Wellens Syndrome - Causes, Diagnosis, and Treatment

What Is Wellens Syndrome?

The term "Wellens syndrome" refers to a pattern of electrocardiographic (ECG) changes that are relatively specific for serious, proximal left anterior descending (LAD) coronary artery stenosis, particularly deeply inverted or biphasic T waves in leads V2 to V3. Alternatively, it is referred to as anterior, descending, T-wave syndrome.

Patients with Wellens syndrome typically don't experience pain when they visit the emergency room, and their cardiac enzyme levels are usually normal or barely elevated. Although these patients are at high risk for a sudden large anterior wall acute myocardial infarction, it is crucial to understand the ECG patterns.

When this syndrome was first discovered in the early 1980s, researchers found that if patients with these ECG findings received only medical management, 75 % of them would experience acute anterior wall myocardial infarction within a few weeks. Percutaneous coronary intervention (PCI) is frequently used as the final form of treatment to open blocked arteries.

Wellens syndrome has similar causes to all conditions that lead to cardiac heart diseases, such as Plaque with atherosclerosis, cardiovascular spasm, and Hypoxia elevated cardiac demand.

What Are the Causes of Wellens Syndrome?

The causes of Wellens syndrome include,

• Atherosclerotic plaque.

• Coronary artery vasospasm.

• Hypoxia.

• Increase in cardiac demand.

How Does Wellens Syndrome Occur?

A temporary blockage of the LAD coronary artery causes Wellens syndrome. Typically, this is brought on by an atherosclerotic plaque rupture that obstructs the LAD and is followed by clot lysis or another type of occlusion disruption before a complete myocardial infarction. Wellens syndrome is a pre-infarction condition. However, these patients are at high risk for severe anterior cardiac wall myocardial infarction and possibly dying because of unstable coronary perfusion. The exact mechanism of Wellens syndrome's ECG changes is unknown, but some speculate that coronary artery spasms and stunned myocardium cause it. Others believe it is caused by repeated transmural ischemia-reperfusion, which causes myocardial edema.

What Are the Risk Factors of Wellens Syndrome?

The risk factors of Wellens syndrome are,

• Diabetes mellitus.

• Family history of premature heart disease.

• Hypertension.

• Increased age.

• Hypercholesterolemia.

• Hyperlipidemia.

• Metabolic syndrome.

• Occupational stress.

• Smoking.

What Is the Prevalence of Wellens Syndrome?

Wellens syndrome is a stage of coronary artery disease before an infarction. Therefore, the same risk factors for Wellens syndrome apply to coronary artery diseases, such as dyslipidemia, hypertension, diabetes, sedentary behavior, obesity, family history, and smoking. Patients who display symptoms consistent with unstable angina are more likely to have the Wellens syndrome ECG pattern. Dr. Wellens and colleagues found the ECG pattern in 14 to 18 % of unstable angina patients. De Zwaan, Wellens, et al. reported a comparable ECG abnormality in 1982. They found that patients with this ECG finding who had been admitted for unstable angina had a high risk of myocardial infarction but they did not mention inverted U-waves.

What Are the Diagnostic Findings of Wellens Syndrome?

• Isoelectric or mildly elevated ST segment of less than 1 mm (no signs of an acute anterior wall myocardial infarction).

• Leads V2 and V3 with deeply inverted T waves (also possible in leads V1, V4, V5, and V6) or T waves in V2 and V3 that are biphasic, with initial positivity and terminal negativity.

• Despite the absence of precordial Q waves, the progression of the precordial R-waves is preserved (which means no signs of old anterior wall infarct).

• Shows ECG pattern in a pain-free state.

• Cardiac markers that are normal or barely elevated.

• Recent history of angina.

What Is the Treatment of Wellens Syndrome?

Consult a cardiologist as soon as Wellens syndrome is identified or suspected. Additionally, speak with an interventional cardiologist as cardiac catheterization with PCI (percutaneous coronary intervention) is the only effective treatment. Until then, treat Wellens syndrome as you would an acute myocardial infarction with aspirin antiplatelet therapy, heparin anticoagulation, nitrates, and beta blockers if the patient is not hypotensive. However, it's crucial to remember that Wellens' patients do poorly under medical management alone and that, as was already mentioned, the only effective treatment is procedural. Admit stable patients who are pain-free on a floor that is under observation.

All symptomatic patients require immediate interventional cardiologist consultation, intensive care up until (ICU) admission, and cardiac catheterization on a more urgent basis. An acute myocardial infarction and sudden death can result from stress testing due to the critical narrowing of the LAD coronary artery in Wellens syndrome patients. The cardiologist can make plans for LAD coronary artery revascularization following coronary angiography.

What Are Some Differential Diagnosis of Wellens Syndrome?

The differential diagnosis for anterior T-wave inversion (TWI) also includes:

• Hypertrophic cardiomyopathy (HOCM).

• Pulmonary embolism (PE).

• Right bundle branch block (RBBB).

• Left ventricular hypertrophy (LVH).

• Central nervous system injury (so-called "cerebral" T waves).

Despite the Wellens pattern being particular for an occlusive plaque of LAD coronary artery stenosis, there are Wellens syndrome mimics, or so-called "pseudo-Wellens syndromes."

Cocaine use, which can cause coronary vasospasm and the well-known Wellens ECG pattern, is one of the causes. The ECG eventually returns to normal because this usually clears up after cocaine is eliminated from the body. Due to the possibility of unopposed stimulation of alpha receptors, administering beta blockers to a young patient without risk factors for acute myocardial ischemia could be harmful. It is essential to be aware of this and to obtain a thorough history.

The Wellens pattern has been linked in some case reports to marijuana use, though the exact reasons are unclear. Myocardial bridging is another uncommon factor that leads to LAD coronary artery stenosis when the coronary artery passes through a bridge of myocardium. The Takotsubo cardiomyopathy, thought to be caused by myocardial edema, also exhibits the Wellens pattern.

Conclusion

A multidisciplinary team composed of a nurse practitioner, primary care physician, cardiologist, and cardiac surgeon performs better when diagnosing and treating Wellens syndrome. The cardiologist needs to be consulted as soon as the diagnosis of Wellens syndrome is confirmed or suspected. Always admit these patients and keep an eye on them. Patient outcomes are poor if treatment is postponed or medical therapy is used, even though the prognosis for patients managed with surgery or PCI is good.