Background

Wellens syndrome was first described in the early 1980s by de Zwaan,

Wellens, and colleagues, who identified a subset of patients with unstable
angina who had specific precordial T-wave changes and subsequently
developed a large anterior wall myocardial infarction (MI). [1] Wellens
syndrome refers to these specific electrocardiographic (ECG) abnormalities in
the precordial T-wave segment, which are associated with critical stenosis of
the proximal left anterior descending (LAD) coronary artery.
Wellens syndrome is also referred to as LAD coronary T-wave syndrome. [2,
3]
Syndrome criteria include the following:
Characteristic T-wave changes
History of anginal chest pain
Normal or minimally elevated cardiac enzyme levels
ECG without Q waves, without significant ST-segment elevation, and
with normal precordial R-wave progression
Recognition of this ECG abnormality is of paramount importance because this
syndrome represents a preinfarction stage of coronary artery disease (CAD)
that often progresses to a devastating anterior wall MI.
Pathophysiology
Wellens syndrome represents critical stenosis of the LAD artery. The LAD
arises from the left coronary artery and travels in the interventricular groove
along the anterior portion of the heart to the apex. This groove is situated
between the right and left ventricles of the heart. The LAD gives rise to 2
main branches, the diagonals and the septal perforators.[4]
A lesion in the LAD can have severe consequences, as suggested by the
common nickname given to this vessel: widow maker. The LAD supplies the
anterior wall of the heart, including both ventricles, as well as the septum.
An occlusion in this vessel can result in serious ventricular dysfunction, thus
placing the patient at serious risk for congestive heart failure (CHF) and
death.
Etiology
Wellens syndrome is a preinfarction stage of CAD. Thus, the causes of
Wellens syndrome are similar to the conditions that cause CAD, including the
following:
Atherosclerotic plaque
Coronary artery vasospasm (cocaine is one possible cause)
Increased cardiac demand
Generalized hypoxia
Risk factors for Wellens syndrome include the following:
Smoking history
 Diabetes mellitus
Hypertension
Increased age
Hypercholesterolemia
Hyperlipidemia
Metabolic syndrome
Strong family history of heart disease
Occupational stress
Epidemiology and Prognosis
The characteristic ECG pattern of Wellens syndrome is relatively common in
patients who have symptoms consistent with unstable angina. Of patients
admitted with unstable angina, this ECG pattern is present in 14-18%.[1, 5]
Wellens syndrome represents critical LAD disease; accordingly, its natural
progression leads to anterior wall MI. This progression is so likely that
medical management alone is not enough to stop the natural process.
Evolution to an anterior wall MI is rapid, with a mean time of 8.5 days from
the onset of Wellens syndrome to infarction.[1]
If anterior wall MI occurs, there is the potential for substantial morbidity or
mortality. Thus, it is of utmost importance to recognize this pattern early.
History
Wellens syndrome represents stenosis of the left anterior descending
coronary artery (LAD), and patients typically present with symptoms or
complaints consistent with coronary artery disease (CAD). Generally, the
history is most consistent with unstable angina. Angina can have varying
presentations, but the classic presentation includes the following complaints:
Chest pain described as pressure, tightness, or heaviness
Pain that is typically induced by activity and relieved by rest
Radiation of pain to the jaw, shoulder, or neck
May experience multiple associated symptoms, including (but not
limited to) diaphoresis, nausea, vomiting, and fatigue
Elderly, diabetic, and female patients are more likely to present with atypical
symptoms.
Physical Examination
Physical examination does not provide any indicators that would give the
examiner strong grounds for suspecting Wellens syndrome. However, the
results of the patients examination may show evidence of ongoing ischemic
damage (eg,congestive heart failure [CHF]).
In addition, most of the electrocardiographic (ECG) changes are recognized
when the patient is pain-free, which again underscores the importance of a
repeat pain-free ECG in the emergency department.