ALL’S WELL(EN) THAT ENDS WELL: A YOUNG LAD WITH WELLEN SYNDROME

Abstract

SESSION TITLE: Cardiovascular Disease 2 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Wellens’ syndrome is a preinfarction stage of coronary artery disease (CAD) that may progress to a major acute cardiac event in the near future if unrecognized or untreated, and can be detected most of the time by its unique pattern of electrocardiographic (ECG) changes in the context of unstable angina characterized by deep inverted T-waves or biphasic T-waves in the precordial leads, namely V2-V3. Human immunodeficiency virus (HIV) infection is known as an independent risk factor for cardiovascular disease. Here we report a case of a patient with history of congenital HIV who presented with chest pain and ECG changes consistent with those described in Wellens' syndrome. CASE PRESENTATION: A 24 year-old male with history of hypertension, HIV, and a family history of premature CAD, was referred from outside hospital for further evaluation and management of chest pain with elevated troponin. He was having new-onset intermittent, non-radiating, exertional, retrosternal pressure-like sensation for 4 days that is relieved with rest. At outside hospital, he was found to have mildly elevated troponin of 0.18 and thus was referred for further management. On presentation to Hartford Hospital, his vital signs were BP 187/123, HR 88, RR 18, SpO2 98% on room air, heart exam revealed normal s1 and s2 with no murmurs, lungs exam revealed good air entry with no crackles or wheezes, chest x ray was negative for acute cardiopulmonary disease, 3 sets of troponin were negative (<0.30 ng/ml), but ECG showed biphasic T-waves in V2-V4 with no ST elevations or Q waves. Given the history of HIV and his family history, CT angiogram coronaries was obtained, which showed proximal left anterior descending (LAD) artery stenosis. Thus coronary angiogram was pursued which revealed 95% proximal LAD occlusion which was treated with a drug-eluting stent, repeat ECG after the cardiac catheterization revealed resolution of the T-wave inversions in V2-V4. DISCUSSION: There are 2 types of Wellens' syndrome based on the ECG pattern; type A which is characterized by biphasic T-waves in V2–V3, and accounts for 25% of Wellens syndrome; and type B which is characterized by deep, symmetric T-wave inversions in V2–V3, and accounts for the remainder 75%, and occasionally those changes can involve leads V1, V4, V5 and V6. Additionally, other criteria have to be met including normal or slightly elevated serum cardiac markers, no loss of precordial R-wave progression, no pathological precordial Q waves, and history of angina. CONCLUSIONS: Patients with Wellens’ syndrome are at high risk of having acute myocardial infarction of the anterior wall. In addition, performing exercise stress test for these patients is contraindicated as it can trigger acute myocardial infarction. Thus, diagnosis of Wellens’ syndrome in patients with anginal pain is crucial and requires urgent percutaneous coronary intervention to prevent fatal sequelae. Reference #1: Tan B, Morales-Mangual C, Zhao D, Khan A, Chadow H. Wellens syndrome in HIV-infected patients: Two case reports. Patanè. S, ed. Medicine. 2017;96(24):e7152. Reference #2: Ashraf FWellens syndrome, a predictor of critical left anterior descending artery stenosis Postgraduate Medical Journal 2017;93:53. Reference #3: wellens syndrome: a life-saving diagnosis 10.1016/j.ajem.2010.10.014 DISCLOSURES: No relevant relationships by saif al-adwan, source=Web Response No relevant relationships by William Duvall, source=Web Response No relevant relationships by Anjana Easwar, source=Web Response No relevant relationships by Peter Montesano, source=Web Response No relevant relationships by Xuan Wang, source=Web Response