Wellen’s Syndrome is one of those syndromes that all emergency physicians know about. It’s probably also one of those syndromes that the emergency community introduced to clinicians everywhere.

It was first described as an inverted U wave as early as 1980 and then introduced by Wellen in 1982 as Wellen’s syndrome, the name by which it is known today(1).

The pattern represents a significant major coronary artery stenosis. If the pattern is not recognised and the patient is untreated, up to 75% of patients will have an anterior wall myocardial infarction within days/weeks.(2) Because of this it has been called “The Widow Maker”.

How to Recognise the Pattern?

The peculiarity of this ECG pattern is that it may not appear when the patient has pain. In fact the only finding when the patient has chest pain, may be a small negative deflection at the end of V1 and V2 . The T waves become deeply inverted when the patient is pain free and represents a reperfusion of the myocardium. Cardiac enzymes will be normal in most cases or mildly elevated.

Wellen’s Patterns

There are two patterns(3):

TYPE A: This occurs in 75% of cases. Has inverted T waves in V2-V3

TYPE B: Occurs in 25% of cases. Has biphasic T waves in V2-3.

 

 

 

 

 

 

 

Characteristics of The Syndrome (4)

  • Recent chest pain history
  • Cardiac Enzymes normal or minimally elevated
  • Deep Twaves or biphasic T wave in V2-V5 in pain free period
  • No Q waves
  • No Loss of R waves
  • Minimal ST elevation

CASE

A 91 yo woman presented to the emergency department with a brief episode of chest pain. On arrival she is pain free. Her ECG below demonstrates Type A Wellen’s pattern. The patient did have a troponin rise and had critical LAD stenosis.

 

Beware when diagnosing Wellen’s Syndrome. Beware the mimics. Look for Pseudo- Wellen’s Syndrome.

References

  1. DeZwaan C et al. Characteristic electrocardiographic pattern indicating a critical stenosis high in left anterior descending coronary artery in patients admitted because of impending myocardial infarction. Amer Heart J. 1982; 103:730-6.
  2. Smith S et al. Acute Coronary Syndromes. Emergency Med Clini of North America. 2006;24:53-89.
  3. Sobnosky S et all.Wellen’s Syndrome. Int J of Cardiol. 2006;3:1
  4. Mead N et al. An ominous EKG pattern. Journal of Emergencies Trauma and Shock. Sept 2009;2(3):206-208