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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 30, No 4, July/August 2019
AFRICA
e1
Case Report
Wellens’ syndrome: a life-saving diagnosis
Yan ming Chen, Kang xing Song
Abstract
Wellens’ syndrome is a relatively common clinical entity;
however, it is often missed, especially in young patients.
Without prompt diagnosis and aggressive intervention,
patients with Wellens’ syndrome may rapidly go on to develop
extensive anterior wall myocardial infarction and possibly
sudden death. In this case report, we present a 33-year-old
male patient with atypical chest pain, and discuss the signifi-
cance of a prompt recognition of Wellens’ syndrome.
Keywords:
Wellens’ syndrome, ECG, electrocardiogram, young
patient, medical education
Submitted 19/1/19, accepted 22/2/19
Published online 24/5/19
Cardiovasc J Afr
2019;
30
: e1–e3
www.cvja.co.zaDOI: 10.5830/CVJA-2019-010
Wellens’ syndrome is a pattern of electrocardiographic T-wave
changes associated with severe stenosis of the left anterior
descending artery (LAD). The risk factors for Wellens’ syndrome
are the same as for acute coronary syndrome, such as diabetes
mellitus, hypertension, hyperlipidaemia, advanced age, and
family history of premature coronary heart disease. However,
it is different from other acute coronary syndromes in that an
electrocardiogram (ECG) obtained during episodes of pain
demonstrates normalisation, and T-wave changes are found
during pain-free periods. Therefore it is inclined to be missed in
young patients without obvious cardiovascular risk factors.
Without prompt diagnosis and aggressive intervention,
patients with Wellens’ syndrome may rapidly go on to develop
extensive anterior wall myocardial infarction and possibly sudden
death. Immediate repetitive ECG evaluation after the chest pain
subsides and timely recognition of this diagnostic ECG pattern
are crucial to decrease cardiovascular risk. Here we report on a
fortunate young man with Wellens’ syndrome who was correctly
diagnosed and treated.
Case report
A 33-year old man was admitted to the hospital because of
intermittent chest pain for seven days. The chest pain was
substernal and ‘prickling’. It occurred in the morning and at
night, and lasted for 10 minutes to a few hours. He had no
history of diabetes, hypertension, hyperlipidaemia, drug abuse
or family history of premature coronary heart disease. He had a
sedentary lifestyle.
The physical examination was unremarkable. The initial
ECG obtained after admission was normal. At 07:40 the next
morning, his pain recurred. An immediate ECG was obtained
and there were no obvious T-wave changes (Fig. 1A). Twenty
minutes later, the pain was relieved with 0.5 mg sublingual
nitroglycerin, and then a pain-free ECG was performed (Fig.
1B), which showed biphasic T waves in leads V2–V4.
The dynamic T-wave changes raised concerns about Wellens’
syndrome, which is associated with severe stenosis of the LAD.
The patient underwent immediate coronary angiography, and the
procedure showed 95% stenosis of the proximal LAD (Fig. 2A);
the stenosis was treated with a drug-eluting stent (Fig. 2B). The
troponin T level rose to a peak of 0.195 ng/ml (normal value
<
0.1 ng/ml).
The patient was discharged home symptom free and referred
to a cardiac rehabilitation programme. He has been in constant
follow up and has not experienced angina again.
Discussion
Wellens’ syndrome is a pre-infarction stage of coronary artery
disease. It comprises 10 to 15% of all acute coronary syndromes
in the USA. However, it is often missed, especially in young
patients.
1-3
Khan reported Wellens’ syndrome in a 24-year-old woman
with atypical chest pain and characteristic ECG changes. This
was initially unrecognised and the young patient subsequently
progressed to an anterior non-ST elevation myocardial
infarction.
4
Wang reported another Wellens’ syndrome in a
22-year-old man.
5
Both young patients in these two cases
had cardiovascular risk factors, namely diabetes and familial
hypercholesterolaemia, respectively.
4,5
Our case was different, as
the young patient has no obvious cardiovascular risk factors or
family history of premature coronary heart disease.
Wellens’ syndrome is prone to misdiagnosis. However the
characteristic ECG pattern is specific for a differential diagnosis.
Wellens’ syndrome, first reported by de Zwaan in 1982, is
a pattern of electrocardiographic T-wave changes associated
with severe stenosis of the LAD.
6
More specifically, Wellens’
syndrome can be classified into two types. Type 1 Wellens
constitutes 24% of cases, is less common, poorly recognised, and
Department of Cardiology, General Hospital of Chinese
PLA, Beijing, China
Yan ming Chen MD,
chenyanmingabcd0@sina.comKang xing Song, MD