Wellens Syndrome: A Case like No Other!

Abstract

Introduction: Wellens syndrome or anterior interventricular artery (AIV) disease is an electrocardiographic abnormality defined by the presence, apart from painful episodes, of biphasic T waves in the anterior leads (type 1), or deeply inverted T waves (type 2) in association with critical stenosis of the proximal AIV. It warrants aggressive management given the rather high incidence of death and re-infarction. Objectif: To report an atypical form of this syndrome through this observation and to provide an update on this rare entity through a literature review. Case report: A 48-year-old patient, chronic smoker with 40 BPs still active, admitted following an episode of infarct chest pain. At admission, the patient was asymptomatic. The clinical examination was unremarkable. The ECG showed biphasic T waves, negative in its terminal part in V2-V3-V4, without planed R waves, nor Q waves of necrosis or significant ST abnormality evoking a WELLENS type 1 syndrome. Ultrasensitive troponin was measured at 260 ng/L. The evolution was marked by the appearance of a fleeting negativation of T waves, without chest pain. Chest echocardiography showed a non-dilated left ventricle with preserved systolic function and no detectable segmental or global kinetic disorders, associated with concentric left ventricular hypertrophy. The coronary angiography performed in emergency shows tritroncular lesions, a very tight stenosis of the middle interventricular and the first diagonal, a tight stenosis of the middle circumflex and the middle right coronary, revealing a coronary artery bypass graft. Discussion and conclusion: Wellens syndrome is characterized by T-wave abnormalities that often fluctuate (from type 1 to type 2 or vice versa) during pain-free intervals, reflecting spontaneous reperfusion and the unstable nature of the coronary lesion found, which is represented mainly by involvement of the proximal AVI. Involvement of the middle IVA associated with other lesions is rarely observed. It is associated with a greater risk of anterior infarction or sudden death if not recognized and treated rapidly, so it seems essential to recognize the electrocardiographic criteria of this syndrome in order to propose coronary angiography for early revascularization.