Case of wellens' syndrome

By Dr : Ahmed abdul hussein

Tellegram channel :AAS medical notes

This ECG for middle age with cardiac pain
What are the ECG findings ??


missing ‫ و ﻛﻠﺶ ﻛﻤﻦ و ﯾﺼﯿﺮ ﺑﯿﮫ‬ECG ‫ﻛﻠﺶ ﻣﮭﻢ ھﺬا ال‬
 ‫ ﻣﺄﺷﺮ ﻋﻠﯿﮭﺎ‬biphasic T wave ‫ ال‬ECG ‫ﺗﺸﻮﻓﻮن ﺑﮭﺬا ال‬
In biphasic T wave ;

v if the first phase is positive and second negative ➡ ischemic changes

v If the first phase is negative and second positive ➡ hypokalemia

‫ھﺎي اﻟﻨﻘﻄﺔ ﻣﺘﻔﻘﯿﻦ ﻋﻠﯿﮭﺎ ھﺴﮫ ؟؟‬

‫ واﻟﮭﺎ اﺳﻢ‬ischemia ‫ﯾﻌﻨﻲ اﻧﻮ اﻛﻮ‬chest leads ‫ب‬biphasic T wave ‫ﻧﻘﻄﺔ أﺧﺮى اﻧﻮ ال‬
wellens' syndrome ‫ﺧﺎص‬

‫؟‬wellen syndrome ‫ﺷﻨﻮ ھﺎي ال‬

Wellens' syndrome : it is significant occlusion in left anterior
descending artery (LAD) .

‫ﺑ ﺲ ﺷ ﻮ ﯾ ﮫ اﻧﺎﺗﻮﻣ ﻲ‬
 ‫ب ‪wellen‬ﻣﻦ ﯾﺼﯿﺮ ‪ occlusion in LAD‬راح ﯾﺼﯿﺮ ‪transient anterior myocardial‬‬
‫‪infarction‬ﯾﻌﻨﻲ وراھﺎ ﺑﺸﻮﯾﮫ راح ﯾﺼﯿﺮ ‪reperfusion‬وﻻن ھﺎي ‪ transientSTEMI‬ف ‪ECG‬‬
‫‪changes of STEMI‬ﻣﺎﻟﺤﮕﺖ ﺗﻈﮭﺮ ﻛﻠﮭﺎ ب ‪ECG‬ﻓﺒﻘﺖ ﺑﻌﺾ ال ‪changes‬اﻟﻲ ھﻲ ه‪biphasic Twave‬‬

‫اﻟﻤﺮﯾﺾ ﺑﻠﺤﻈﺔ ﻣﻦ ﺻﺎر ﻋﺪة ‪occlusion in LAD‬راح ﯾﺠﻲ ب ‪chest pain‬ﺑﺲ ﻻن ھﺎﻟﻌﻤﻠﯿﮫ‬
‫‪transient‬ﻣﻦ ﯾﺼﯿﺮ ‪reperfusion‬راح ﯾﺮوح اﻷﻟﻢ وﻣﻤﻜﻦ واﺻﻞ ﻟﻠﻄﻮارئ وﻋﻨﺪة ﺑﺲ ‪ECG‬‬
‫‪manifestations‬اﻟﻤﺘﻤﺜﻠﺔ ﺑﺎ ‪biphasic T wave‬‬
‫ﺗﻤﺎم ؟؟‬

‫ھﻨﺎ ﻧﻘﻄﺔ ﻣﮭﻤﺔ ;‬

‫‪ v‬اذا ﺑﻘﻰ اﻻرﺗﺮي ﻣﻔﺘﻮح راح ﺗﺘﺤﻮل ال ‪biphasic Twave‬اﻟﻰ ‪ deep inverted Twave‬وھﺎي‬
‫ﯾﺴﻤﻮھﺎ ‪wellens syndrome Type B‬‬

‫** ﻟﻠﻌﻠﻢ اﻧﻮ ‪ biphasic T wave‬ھﻲ ال ‪wellen syndrome type A‬‬

‫ھﻨﺎ ﺳﺆال ‪ :‬ھﻞ ھﺬا اﻻرﺗﺮي ﯾﺒﻘﻰ ﻣﻔﺘﻮح ﻣﺎﯾﻨﺴﺪ ؟‬

‫اﻟﺠﻮااب ﻻ ﻻن ھﺬا اﻻرﺗﺮي ھﻨﺎ ﺑﮭﺎي اﻟﺤﺎﻟﺔ اﻧﺴﺘﯿﺒﻞ ﻓﺄﺣﺘﻤﺎل ﻛﻠﺶ ﻋﺎﻟﻲ ااذا ﺗﻌﻮﻓﮫ ﺑﺪون ‪invasive‬‬
‫‪ therapy‬رااح ﯾﺼﯿﺮ ‪ re occlusion‬و ‪established STEMI‬‬

‫د اﺣﻤﺪ ھﻨﺎ ﯾﮕﻮل ﺗﺨﯿﻞ وﯾﺎي اﻟﺴﻠﺴﻠﮫ‬

‫😁‬

‫‪➡ wellen type B‬وﺑﻘﻰ اﻻرﺗري ﻣﻔﺗوح ھﻧﺎ رااح ﯾﺗﺣول ‪Occlusion ➡reperfusion‬‬
‫‪If occur reocclusion after reperfusion ➡normalization of Twave‬‬

‫اﻟﻘﺻد ﻣن ھذا اﻟﻛﻼم اذا ﺻﺎر ‪reocclusion‬ﻣره ﺛﺎﻧﯾﮫ راح ﯾﺻﯾر ال ‪t wave‬ﺗرﺟﻊ ﻟﺷﻛﻠﮭﺎ اﻟﻧورﻣﺎل‬
‫وھﺎي ﯾﺳﻣوھﺎ ‪pseudo normalization‬واﺧطر ﺷﻲ )ﺋﺧﻠﻲ ﺟواھﺎ ‪ ١٩٩٧٨٦‬ﺧط اﺣﻣر ( ﻟﯾش ؟؟‬

‫ﻻن ﻣن راح ﺗﺳوي ‪ECg‬راح ﺗﻠﮕﺎه ﻧورﻣل ﺑس ھو اﻟﺑﯾﺷﻧت ﯾﻌﻧﻲ ﺣﺎﻟﺗﮫ ﺣﺎل ‪MI‬‬

‫ﻓﺄﻧت ﻻﺗﻧﺧدع اذا ﻣﺳوي ‪ Serial ECG‬وﻟﮕﯾت ﺑواﺣد ﻣﻧﮭن ‪biphasic Twave‬وﺑﻌدﯾن ﺻﺎﯾر ال ‪t‬‬
‫‪wave‬ﻧورﻣل وﻋﺑﺎﻟك اﻧت ﻣﺎﺷﻲ ﺻﺢ ؛ ﻻ ﻻ ﺗﻧﺧدع ھﻲ ھﺎي ‪pseudonormalization‬وھذا اﻟﺑﯾﺷﻧت‬
‫ﯾﻌﺎﻣل ﻣﻌﺎﻣﻠﮫ ا ‪Mi‬وﯾﺣﺗﺎج ‪urgent PCI‬‬
 ‫‪ v‬ﺗذﻛروا ھﺎي اﻟﻧﻘطﺔ اﻧو اﻟﺑﯾﺷﻧت أﺑو ‪wellen‬ﯾﺟﻲ ﻟﻠطوارئ ‪pain free‬ﻻن ﯾﺻﯾر‬
‫رﺑرﻓﯾوﺷن ﺗﻠﻘﺎﺋﯾﺎ ً‬
‫‪ v‬وﺗذﻛروا ان ‪wellen‬ﺗﻌﺗﺑر ‪STEMI equivalent‬‬
‫‪ v‬وﺧﻠﻲ ﺑﺑﺎﻟﻲ اﻧو أﺑو ‪wellen‬ﺗﺣوﻟﮫ ﻟل ‪heart center‬ﻻﺗﺗرﻛﮫ ﺑﺎﻟطوارئ؛ واﺟﺑك‬
‫ﺗﺷﺧﺻﮭﺎ وﺗﺣوﻟﮭﺎ ﻟل ‪heart center‬‬

‫ﻧﻘطﺔ ﻣﮭﻣﺔ ﺟدا ً ‪:‬‬

‫اﻛو ﺑﯾﮭم ﯾﻘوﻟون ال ‪wellen‬ﻻن ﯾﺻﯾر ‪ LAD occlusion‬ﻓﺎ ‪T wave changes‬ﺗﺑﻘﻰ ﻓﻘط ﺑﻠﯾدات‬
‫‪v1‬و ‪v2‬و ‪ v3‬ﻻ اﺑدا ً ھذا اﻟﻛﻼم ﻣو ﺻﺣﯾﺢ‬

‫ﻟﯾش؟؟؟‬
‫ﻻن ال ‪wellen‬ﻣرات ﯾﺻﯾر ‪ occlusion of left main artery‬ﯾﻌﻧﻲ ال ‪wellen‬ﻣﻣﻛن ﺗﺗﺿﻣن‬
‫‪LAD‬و ‪left main arterty‬ف ‪ECG changes‬ﻣﻣﻛن ﺗﻠﮕﺎھﺎ ‪extended throughout‬‬
‫‪precordial lesds‬ھﺎي اﻟﻧﻘطﺔ ﻣﮭﻣﺔ وﻻﺗﻧﺧدع ﺑﯾﮭﺎ ﺑﺎﻟﺗﺷﺧﯾص‬

‫ھﻧﺎ ﺳوال ﻣﮭم‬

‫ھل ﻛل ‪deeply inverted T wave in precordial leads‬ﺗﻌﺗﺑرھﺎ ‪wellen‬؟‬

‫ﻻ اﺑدا ً ﻣو ﺻﺣﯾﺢ ھﺎﻟﺷﻲ ﻧﮭﺎﺋﯾﺎ ً ﻣوﺻﺣﯾﺢ ھﺎﻟﺷﻲ ﻟﯾش ؟‬

‫‪Most important thing is to exclude ddx of wellen‬‬

‫اھم ‪ddx‬ھو ‪pulmonary embolism‬‬

‫وھﺎي ﺷﻠون ﺗﻣﯾز ھﺎي ‪deep inverted t wave‬ﻣﺎل ‪PE‬ﻣو ‪wellen‬؟‬

‫ﻣن ﺧﻼل ال ‪clinical presentation‬‬
‫وﻣن ﺧﻼل ‪deep inverted T wave in V1and lead 3‬وھﺎي ﯾﺳﻣوھﺎ ‪pseudo wellen‬‬
‫‪phenomenon‬‬
‫ﻣن ﮔد ﻣﺎﺗﺧﻠﯾك ﺗﺷﺗﺑﮫ ﺑﯾﮭﺎ وﺑﯾن ‪wellen‬‬

‫واﻛو ﺑﻌد ‪ddx‬واﺿﺣﺎت ﻣﺛل ‪RBBB‬و ‪LVH‬و اﻛو ‪posterior MI‬و اﻛو ﺑﻌد ‪DDX‬ﺑس اﻟﻣﮭم واﻻھم‬
‫ﺗﺗذﻛر ال ‪PE‬ك ‪DDX‬‬
 Tx of wellen
Asprin 300 mg chewable
Metoprolol 5 mg IV
Angised

Refferal to heart center for urgent PCI

wellens' syndrome ‫ھذا ﻛل اﻟﻲ ﻻزم ﺗﻌرﻓﮫ واﻟﻣﮭم ﻋن‬

Thank
you