Type A Wellens' syndrome - A critical electrocardiographic sign

Abstract

Wellens’ syndrome was first described in 1982[1] and classified into type A and type B. Type A Wellens’ syndrome is characterized by biphasic T-waves in leads V2 and V3, and type B is characterized by deep symmetrical T-wave inversions in the same leads. The study reported that Wellens’ syndrome electrocardiographic (ECG) finding related to left anterior descending (LAD) total or near-total occlusion, which is also described as one of the ST-segment elevation myocardial infarction (STEMI) equivalent signs.[2] Cardiology consultation for possible coronary angiography is necessary for evaluating patients.[3] A 29-year-old male without underlying medical diseases was admitted to our emergency department due to intermittent retrosternal chest tightness for 1 week. His chest pain usually occurs after exertion, accompanied by nausea and dizziness, and subsides 10–15 min after rest. He did not notice other exacerbating or relieving factors. Thus, he visited our emergency department for a consultation. The patient is a nonsmoker with no family history of acute coronary syndrome. In the emergency department, his chest pain had already subsided. He was vitally stable. On physical examination, his cardiac auscultation revealed a regular heartbeat with no murmurs. His ECG performed in the emergency department showed sinus rhythm with biphasic T-waves in leads V2 and V3 without precordial Q waves [Figure 1], which is compatible with type A Wellens’ syndrome. As for his blood examination, his troponin I level is 3.2 ng/mL (normal range < 0.02 ng/mL) and creatine kinase-myocardial band mass is 8.5 ng/mL (normal range <5 ng/mL). He also had thrombocytosis with a platelet count of 993,000/μL.Figure 1: Patient’s initial ECG. ECG: ElectrocardiographicThe patient received aspirin, ticagrelor, and heparin for the myocardial infarction. He received urgent coronary angiography and the examination showed an 85% stenosis of the proximal LAD artery [Figure 2] that was successfully opened through angioplasty. Two drug-eluted stents were placed. After angioplasty, his ECG showed sinus rhythm with no Wellens’ pattern. In addition, he did not experience any chest pain attack after angioplasty. On admission, the patient was diagnosed with essential thrombocythemia through positive JAK-2 V617F mutation test and bone marrow biopsy.Figure 2: Patient’s coronary angiography showed LAD stenosis. (Left) Before the intervention. (Right) After the intervention. LAD: Left anterior descendingWellens’ syndrome is one of the STEMI equivalent ECG signs that need to be treated as acute myocardial infraction in the emergency department.[2] A previous study[1] showed that 75% of the patients with Wellens’ syndrome developed extensive anterior wall myocardial infarction a few weeks after admission. T-wave findings of Wellens’ syndrome are classified into two patterns. In type B, which comprises approximately 75% of cases, the T-wave is deeply inverted and the inverted T-wave is symmetric in contour. In type A, which comprises 25% of cases, the T-wave is biphasic in leads V2 and V3. Other ECG criteria included no loss of R rave or precordial Q waves. Considering noncoronary causes of T-wave inversions, the left ventricular hypertrophy and bundle branch block patterns should be readily recognized by their significant coexistent findings.[3] The characteristic ECG pattern often develops when the patient is not experiencing angina.[3] Patients with ET may present with vasomotor symptoms such as myocardial infarction or stroke. However, in this case, the patient was young and without any risk factors for myocardial infarction before diagnosis. Prompt recognition of the ECG pattern and early cardiology consultation are essential to prevent missing the diagnosis of myocardial infarction. Declaration of patient consent The authors certify that they have obtained appropriate patient consent form. In the form, the patient has given his consent for the images and other clinical information to be reported in the journal. The patient understands that name and initial will not be published and due efforts will be made to conceal the identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.