Wednesday, 27 November 2013

ECG of the Week - 25th November 2013 - Interpretation

This week's ECG is from a 56 yr old male who presented with episodic chest pain over the preceding few days. He is a hypertensive smoker. He was pain free when this ECG was performed.
Check out our original post and comments here.





Click to enlarge
Rate:
  • 78
Rhythm:
  • Regular
Axis:
  • Normal ( 40 deg)
Intervals:
  • PR - Normal (~140ms)
  • QRS - Normal (80ms)
  • QT - 400ms (QTc Bazette ~ 450 ms)
Segments:
  • Up-sloping ST Elevation V1-4 (1mm)
  • Subtle ST Depression Lead II
Additional:
  • Voltage Criteria LVH
  • Q waves Leads II, III, aVF, V4-V6
  • Biphasic T waves V1-4
    • Positive to negative deflection
  • T Inversion Lead III
  • Notched P wave Leads II, III
Interpretation:
  • Given clinical history of chest pain and T wave morphology ECG features suggestive of Wellens' Syndrome (type 2)
Wellens' Syndrome

Wellens' Syndrome represents critcal LAD disease with a mean time to infarction of ~8 days. 

ECG features of Wellens' are:
  • Type 1 Pattern - deep symmetrically inverted T waves in leads V2 & V3 
  • Type 2 Pattern - positive to negative biphasic T waves in leads V2 & V3
With:
  • No pathological precordial q waves and no loss of R wave progression
  • Patient with history of chest pain
Note:
  • Typical Wellens' ECG features usually occur on the painfree ECG
  • T wave changes may extend into the lateral precordial leads.
  • Patients may have normal biomarkers.
  • Exercise stress testing may precipitate acute infarction and should be avoided
Who is Hein J. J. Wellens ?

Whilst many Emergency Physicians and Cardiologists recognise the name Wellens his contribution and association with cardiology has been far more extensive than the clinical entity highlighted in this post.
Wellens is one of the founders and pioneers of cardiac electrophysiology and I would encourage our readers to seek inspiration from his biography.



What Happened Next ?

The patient gave a history strongly suggestive of cardiac chest pain and was discussed with the cardiology team. Following initial treatment with aspirin, clopidogrel, heparin the patient was transferred to another facility for ongoing management. His initial troponin I result was elevated at 2.3 mcg/L [normal <0.05] and the patient underwent angiography & PCI that day.
His angiography showed:
  • LAD - Critical proximal stenosis --> stented
  • LCx - moderated mild disease
  • RCA - moderate proximal disease
  • LV - global hypokinesia
Unfortunately I was unable to access this patient's echocardiogram or clinical outcome.

Wellens' On The Web

In the interest of not re-inventing the wheel here are some great web resources on Wellens' Syndrome


References / Further Reading
Textbook
  • Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.