Wellens syndrome

Pattern of T-wave abnormality in mid precordial leads (V2-V3, +/- V4)
No loss of R-waves in precordial leads
Highly specific for critical obstruction of the proximal LAD
High risk for extensive anterior wall MI and death
Type 1 – Deeply symmetric TWI
Type 2 – Biphasic T waves with terminal TWI. Goes up first, then down (often misdiagnosed as “normal” or “non-specific T-wave abnormality”). Often misdiagnosed as “non-specific T-wave pattern” or “normal”.
ST changes are often absent and patient can be in a chest pain free state!
Cardiac biomarkers often initially normal
Best to diagnose in absence of high voltage
Not currently a guideline indication for cath or lytics (especially when pain free without STE) but…
Medical management usually ineffective and patients are best treated with PCI, treadmill stress testing may be hazardous and precipitate acute MI.
Patients will have anterior wall MI unless they get early PCI. 75% developed acute MI within weeks when only medically managed.
Get serial ECG’s, as some of these do evolve into STEMI in the ED
Watch carefully for Wellens’ as some of your consultants may not know about this.

DDx

normal variant ST elevation & TWI