Ischæmia and Wellens’ Warning

Report:

Atrial rhythm 68/min (first 6 beats)

Sinus rhythm 54/min (last 5 beats)

T wave changes c/w ischæmia

Borderline LVH voltage (R2 15mm)

Comment:

In V1-3 the T waves, even though within normal limits by themselves, appear unduly prominent compared to those further left. Indeed, there is TV1 > TV6 as well as T3 > T1: subtle but important signs of ischæmia. This trace may well represent early acute infarction as well as reversible ischæmia – electrocardiography has its limitations. It should be enough, however, to report one or the other.The presence of atrial (possibly junctional, or low-atrial, with retrograde P morphology, or coronary sinus) rhythm does not have diagnostic significance. Still, it may have some survival value, alerting the Casualty staff that something is going on!

The ECG morphed into Wellens’ warning, with inverted or inverted terminal Ts in the same V1-3 leads that showed prominent T waves with chest pain on admission (Fig 36a). This configuration is a sign of tight proximal LAD artery (the widow-maker) stenosis33. It’s called Wellens’ syndrome or Wellens’ warning. The patient indeed had 90% proximal LAD artery stenosis, with some fresh thrombus thrown in.

Figs 36b an 36c are tracings of a similar patient, a 61 year old man with crescendo angina, also with proximal 90% LAD lesion.

The problem with remembering Wellens’ syndrome is where to put the apostrophe.