Pain free ECG changes

by Adam Herbstritt

This 60 year old Male had developed chest pain over the last month. No prior history of ischaemic heart disease. Episodes were fairly typical for angina. He'd presented to ED for the first time on the 3rd of these episodes, having been abroad on holiday for the previous 2. He was pain free when this ECG was taken.

What do you think?

This is sinus rhythm 60reg (not 112 as the ECG computer reads!)
There are biphasic T waves in V1 & 2, as well as inversions in V4&5 and more biphasic T's in III and av.

Biphasic or deep T waves in the anterior leads in a pain free patient are typical for Wellens Syndrome, and is highly specific for a critical stenosis of the left anterior descending artery (LAD).  Indeed this was the finding on this mans angio later that day.

These patients usually require invasive therapy, do poorly with medical management and may suffer MI or cardiac arrest if inappropriately stress tested. This should be stressed to the cardiology reg, who may not be aware of the importance of this finding, and not just be sent to MAU for follow up troponins.

Read more on these excellent online resource;

http://lifeinthefastlane.com/ecg-library/wellens-syndrome/
http://hqmeded-ecg.blogspot.co.uk/2011/10/wellens-syndrome-no-culprit-what.html

Comments welcomed.