Wellens, Until It Wasn’t
TLDR
An overnight ECG read shows a Type B Wellens-like pattern in an admitted patient — but the full clinical picture tells a very different, and tragic, story. A case on why history must always anchor ECG interpretation.
Called Overnight for an ECG
I was called overnight to read an ECG for an admitted 60 year old female. Past medical history was significant for a history of lung cancer with recent pneumonectomy, and cardiac history only significant for paroxysmal AF for which she was anticoagulated.
The ECG sent to me overnight.
The Admission
She had been admitted earlier in the day for what was described as a near syncopal event without head trauma. She was noted to have an abnormal CXR, and a CTA demonstrated a large pleural effusion without pulmonary emboli. Her ECG was the same as that sent to me overnight and was acknowledged to be abnormal, as it had been followed up with a posterior ECG.
I called the floor to double check the ECG was for chest pain — as was typical. The nurse seemed unsure. I called the cardiology fellow on call, who was in house overnight, and told them my concern over the recent ECG showing a Wellens-like pattern concerning for a critical lesion if truly in the setting of recent chest pain. I recommended they evaluate the patient face to face, as I could not, to evaluate for possible catheterization / ACS meds. I went and found the overnight hospitalist, showed them the ECG, discussed my concerns and let them know I called the on-call cardiologist. They told me they planned to go see the patient and, reassuringly, if representing ischemia, they were already on a heparin drip for their atrial fibrillation.
An old ECG for comparison, a month prior.
A Quick Review of Reperfusion Waves
A quick review of reperfusion waves associated with Wellens syndrome. The syndrome describes characteristic findings in the anterior leads associated with a critical lesion in the LAD in a patient with recent chest pain, upon resolution of pain. The first pattern of these changes, Type A, involves biphasic T waves — first rising before falling below the isoelectric line. While symmetric T wave inversions are characteristic of a Type B pattern.
In this case I was seeing a Type B pattern; although, importantly, the diagnosis of this syndrome requires a history of recent chest pain with the ECG during a pain-free interval. Special care should be made to not anchor on it without the full clinical picture. This was the reason for my call to the cardiology fellow and discussion with the hospitalist — both of whom could see the patient bedside.
Wellens reperfusion patterns: Type A biphasic T waves and Type B symmetric T wave inversions.
Differentials for a Type B Pattern
Other differentials for Type B Wellens syndrome include apical hypertrophic cardiomyopathy, takotsubo, and, less commonly in my experience, pulmonary emboli with heart strain. While apical hypertrophic cardiomyopathy shows the T wave changes more laterally in the precordial leads or also in other groups such as inferior leads — I have seen Wellens extend out to V5–V6 in some cases. Academic differentiators include the R wave amplitude potentially being larger in the lateral leads in apical HCM (makes sense as the area of hypertrophy). In all cases, the QT can be prolonged, but most severely in takotsubo.
I say these differentiators are “academic” because the most reliable and consistent way to differentiate is clinically, based on history. Wellens syndrome will have dynamic ECG changes between pain-free intervals when the Type A or B pattern emerges and episodes of active pain, where pseudonormalization to an upright T wave can be indicative of the critical lesion now becoming obstructive and need for prompt reperfusion regardless of a lack of ST elevation. The T waves in pseudonormalization in my experience often show striking loss of T wave contour, leading to an overall more symmetric appearance when compared to a patient’s baseline, and may be associated with QRS distortion or loss of an S wave previously present. The dynamism of ECG changes in Wellens syndrome is also seen during long pain-free intervals, when Type A may begin to change into a Type B pattern for example. This is much different from your apical HCM, which will have relatively static serial ECGs and often presents without anginal complaints or shows no change between anginal and pain-free intervals. A bedside echocardiogram can aid further between takotsubo, apical HCM, and Wellens syndrome.
Back to the Case
Back to the case — which is neither apical HCM, Wellens syndrome, or takotsubo. The following day I checked in on the chart and learned that in addition to the fellow and hospitalist seeing the patient overnight, an attending cardiologist had seen her early in the morning. They remarked that there was little clinically to suggest ACS; the patient only complained of a headache and denied recent chest pain. The ECG remained unchanged, with a pattern suggesting the possibility of Type B Wellens syndrome. The changes in the ECG were attributed potentially to her pneumonectomy. A nursing note later remarked how the patient suffered from migraines and complained of her usual migraine, requesting pain medication. Later that day the patient was found unresponsive. A CT scan showed a catastrophic ICH with uncal herniation, and the patient sadly died shortly after.
The Full Clinical Picture Prevails
While in this case anticoagulation was already started on the patient regardless of ECG findings, I find it hard to imagine a better case to drive home the importance of the full clinical picture in any ACS diagnosis. It’s easy to imagine an overnight situation where, as an ED physician, you are called to read an ECG overnight, obtained for only partially clear reasons, and assume the responsibility to act appropriately on it. Perhaps in another patient they wouldn’t be on an anticoagulant already, and a knee-jerk ordering of ACS medications could have drastically changed the outcome for the worse.
Though believed to be less common, T wave inversions, biphasic T waves, and a “Wellens” type pattern can all be seen with elevated ICP and massive ICH. Again, the clinical picture will prevail as, at least from documentation, chest pain was missing while a headache was present.
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Wellens, Until It Wasn’t
TLDR
An overnight ECG read shows a Type B Wellens-like pattern in an admitted patient — but the full clinical picture tells a very different, and tragic, story. A case on why history must always anchor ECG interpretation.
Called Overnight for an ECG
I was called overnight to read an ECG for an admitted 60 year old female. Past medical history was significant for a history of lung cancer with recent pneumonectomy, and cardiac history only significant for paroxysmal AF for which she was anticoagulated.
The ECG sent to me overnight.
The Admission
She had been admitted earlier in the day for what was described as a near syncopal event without head trauma. She was noted to have an abnormal CXR, and a CTA demonstrated a large pleural effusion without pulmonary emboli. Her ECG was the same as that sent to me overnight and was acknowledged to be abnormal, as it had been followed up with a posterior ECG.
I called the floor to double check the ECG was for chest pain — as was typical. The nurse seemed unsure. I called the cardiology fellow on call, who was in house overnight, and told them my concern over the recent ECG showing a Wellens-like pattern concerning for a critical lesion if truly in the setting of recent chest pain. I recommended they evaluate the patient face to face, as I could not, to evaluate for possible catheterization / ACS meds. I went and found the overnight hospitalist, showed them the ECG, discussed my concerns and let them know I called the on-call cardiologist. They told me they planned to go see the patient and, reassuringly, if representing ischemia, they were already on a heparin drip for their atrial fibrillation.
An old ECG for comparison, a month prior.
A Quick Review of Reperfusion Waves
A quick review of reperfusion waves associated with Wellens syndrome. The syndrome describes characteristic findings in the anterior leads associated with a critical lesion in the LAD in a patient with recent chest pain, upon resolution of pain. The first pattern of these changes, Type A, involves biphasic T waves — first rising before falling below the isoelectric line. While symmetric T wave inversions are characteristic of a Type B pattern.
In this case I was seeing a Type B pattern; although, importantly, the diagnosis of this syndrome requires a history of recent chest pain with the ECG during a pain-free interval. Special care should be made to not anchor on it without the full clinical picture. This was the reason for my call to the cardiology fellow and discussion with the hospitalist — both of whom could see the patient bedside.
Wellens reperfusion patterns: Type A biphasic T waves and Type B symmetric T wave inversions.
Differentials for a Type B Pattern
Other differentials for Type B Wellens syndrome include apical hypertrophic cardiomyopathy, takotsubo, and, less commonly in my experience, pulmonary emboli with heart strain. While apical hypertrophic cardiomyopathy shows the T wave changes more laterally in the precordial leads or also in other groups such as inferior leads — I have seen Wellens extend out to V5–V6 in some cases. Academic differentiators include the R wave amplitude potentially being larger in the lateral leads in apical HCM (makes sense as the area of hypertrophy). In all cases, the QT can be prolonged, but most severely in takotsubo.
I say these differentiators are “academic” because the most reliable and consistent way to differentiate is clinically, based on history. Wellens syndrome will have dynamic ECG changes between pain-free intervals when the Type A or B pattern emerges and episodes of active pain, where pseudonormalization to an upright T wave can be indicative of the critical lesion now becoming obstructive and need for prompt reperfusion regardless of a lack of ST elevation. The T waves in pseudonormalization in my experience often show striking loss of T wave contour, leading to an overall more symmetric appearance when compared to a patient’s baseline, and may be associated with QRS distortion or loss of an S wave previously present. The dynamism of ECG changes in Wellens syndrome is also seen during long pain-free intervals, when Type A may begin to change into a Type B pattern for example. This is much different from your apical HCM, which will have relatively static serial ECGs and often presents without anginal complaints or shows no change between anginal and pain-free intervals. A bedside echocardiogram can aid further between takotsubo, apical HCM, and Wellens syndrome.
Back to the Case
Back to the case — which is neither apical HCM, Wellens syndrome, or takotsubo. The following day I checked in on the chart and learned that in addition to the fellow and hospitalist seeing the patient overnight, an attending cardiologist had seen her early in the morning. They remarked that there was little clinically to suggest ACS; the patient only complained of a headache and denied recent chest pain. The ECG remained unchanged, with a pattern suggesting the possibility of Type B Wellens syndrome. The changes in the ECG were attributed potentially to her pneumonectomy. A nursing note later remarked how the patient suffered from migraines and complained of her usual migraine, requesting pain medication. Later that day the patient was found unresponsive. A CT scan showed a catastrophic ICH with uncal herniation, and the patient sadly died shortly after.
The Full Clinical Picture Prevails
While in this case anticoagulation was already started on the patient regardless of ECG findings, I find it hard to imagine a better case to drive home the importance of the full clinical picture in any ACS diagnosis. It’s easy to imagine an overnight situation where, as an ED physician, you are called to read an ECG overnight, obtained for only partially clear reasons, and assume the responsibility to act appropriately on it. Perhaps in another patient they wouldn’t be on an anticoagulant already, and a knee-jerk ordering of ACS medications could have drastically changed the outcome for the worse.
Though believed to be less common, T wave inversions, biphasic T waves, and a “Wellens” type pattern can all be seen with elevated ICP and massive ICH. Again, the clinical picture will prevail as, at least from documentation, chest pain was missing while a headache was present.
Comments