Wellens' syndrome

Wellens' syndrome (or sign, or occasionally warning) is an electrocardiographic manifestation of critical proximal left anterior descending (LAD) coronary artery stenosis in patients with unstable angina. It is characterized by symmetrical, often deep >2mm, T wave inversions in the anterior precordial leads. A less common variant is biphasic T wave inversions in the same leads.

First described by Hein J. J. Wellens and colleagues in 1982 in a subgroup of patients with unstable angina, it does not seem to be rare, appearing in 18% of patients in his original study. A subsequent prospective study identified this syndrome in 14% of patients at presentation and 60% of patients within the first 24 hours.

The presence of Wellens' syndrome carries significant diagnostic and prognostic value. All patients in the De Zwann's study with characteristic findings had more than 50% stenosis of the left anterior descending artery (mean=85% stenosis) with complete or near-complete occlusion in 59%. In the original Wellens' study group 75% of those with the typical syndrome manifestations had an anterior myocardial infarction. Sensitivity and specificity for significant (more or equal to 70%) stenosis of the LAD artery was found to be 69% and 89% respectively with positive predictive value 86%.

Wellens' sign has also been seen as a rare presentation of Takotsubo or stress cardiomyopathy.

Diagnostic criteria

• Progressive symmetrical deep T wave inversion in leads V2 and V3
• Slope of inverted T waves generally at 60°-90°
• Little or no cardiac marker elevation
• Discrete or no ST segment elevation
• No loss of precordial R waves.

File:Wellensekg.jpg

EKG showing Wellens' syndrome, note the inverted T waves in leads V2 and V3