Circulation

CASES AND TRACES

Wellen’s Syndrome
The Life-Threatening Diagnosis

ECG CHALLENGE Omar Al-assaf, MD

A 34-year-old male was referred to our emergency department complaining of Mouayad Abdulghani,
typical cardiac chest pain, which started 12 hours before presentation with no MD
associated symptoms. The patient was a smoker and had no family history of any Anas Musa, MD
cardiac disease. On physical examination he was vitally stable, and cardiac auscul- Muna AlJallaf, MD
tation revealed normal first and second heart sounds with no murmurs. Other sys-
temic examinations were normal. Laboratory investigations showed elevated car-
diac enzymes, whereas other routine laboratory results were within normal ranges.
Figure 1 shows the patient’s initial ECG.
Please turn the page to read the diagnosis.
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Figure 1. Patient’s initial ECG.

aVF, aVL and aVR indicate the limb leads.

Key Words:  coronary angiography

◼ electrocardiography ◼ myocardial
infarction

© 2019 American Heart Association, Inc.

https://www.ahajournals.org/journal/circ

Circulation. 2019;140:1851–1852. DOI: 10.1161/CIRCULATIONAHA.119.043780 November 26, 2019 1851

 Al-assaf et al
RESPONSE TO ECG CHALLENGE
CASES AND TRACES
The patient’s initial ECG showed normal sinus rhythm
with a biphasic T wave starting from V1–V4 pericardial
chest leads with minimal ST elevation in V3, indicating
Wellen’s syndrome type A.
The patient was taken for an urgent coronary angi-
ography that showed a proximal total occlusion of the
left anterior descending artery (LAD). Two drug-eluted
stents were placed with positive outcome. The patient
was discharged 3 days later in a stable condition and
pain-free.
Wellen’s syndrome, also called LAD coronary syndrome
or widow maker, was first described in 1982 by de Zwaan
et al1 in a subgroup of patients with unstable angina dur-
ing a pain-free period. Seven years later, the same authors
performed another prospective study on patients with
Wellen’s syndrome and confirmed 100% association with
a significant proximal LAD disease by cardiac coronary an-
giography.2 Wellen’s syndrome is classified into type A or
type B. Type A is characterized by biphasic T wave in leads
V2 and V3, whereas type B is characterized by deep T-
wave inversion in the same leads. However, in both types
these ECG changes can extend to involve any pericardial
chest leads, as in our case.1
In general, biphasic T wave has a wide differential
diagnosis. The criteria used to diagnose Wellen’s syn-
drome include symmetric and deeply inverted T waves
or biphasic T waves in leads V2 and V3 in a pain-free
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state, plus isoelectric or minimally elevated (<1 mm) ST
segment. In addition, the criteria require the absence of
precordial Q waves, the presence of history of angina,
and normal or slightly elevated cardiac serum markers.3
1852 November 26, 2019
Wellen’s Syndrome
The first study done by de Zwaan et al1 showed that
75% of the patients who had Wellen’s syndrome devel-
oped extensive anterior wall myocardial infarction a few
weeks after admission. Furthermore, the study reported
that Wellen’s syndrome ECG finding indicates LAD to-
tal or near-total occlusion. Thus, coronary angiography
and revascularization are strongly recommended.1
‍ARTICLE INFORMATION
Correspondence
Omar Yousef Al-assaf, MD, Internal Medicine Department, Rashid Hospital,
Dubai Health Authority, Dubai, U.A.E. Email oyalassaf@dha.gov.ae
Affiliations
Internal Medicine Department (O.A.), Emergency Department (M. Abdulghani,
M. AlJallaf), and Cardiology Department (A.M.), Rashid Hospital, Dubai Health
Authority, United Arab Emirates.
Disclosures
None.
REFERENCES
1. de Zwaan C, Bär FW, Wellens HJ. Characteristic electrocardiographic pat-
tern indicating a critical stenosis high in left anterior descending coronary
artery in patients admitted because of impending myocardial infarction.
Am Heart J. 1982;103:730–736. doi: 10.1016/0002-8703(82)90480-x
2. de Zwaan C, Bär FW, Janssen JH, Cheriex EC, Dassen WR, Brugada P,
Penn OC, Wellens HJ. Angiographic and clinical characteristics of patients
with unstable angina showing an ECG pattern indicating critical narrow-
ing of the proximal LAD coronary artery. Am Heart J. 1989;117:657–665.
doi: 10.1016/0002-8703(89)90742-4
3. Rhinehardt J, Brady WJ, Perron AD, Mattu A. Electrocardiographic mani-
festations of Wellens’ syndrome. Am J Emerg Med. 2002;20:638–643.
doi: 10.1053/ajem.2002.34800
Circulation. 2019;140:1851–1852. DOI: 10.1161/CIRCULATIONAHA.119.043780