Makindo Medical Notes

Related Subjects: |Atherosclerosis |Ischaemic heart disease |Assessing Chest Pain |Acute Coronary Syndrome (ACS): Complications |ACS - General |ACS - STEMI |ACS - NSTEMI |ACS - GRACE Score |ACS - ECG Changes |ACS -Cardiac Troponins |ACS - Post MI arrhythmias |ACS: Right Ventricular STEMI |ACS: Sgarbossa Criteria |Wellen's syndrome

Because Wellens syndrome patients have critical narrowing of the LAD coronary artery, a stress test should be avoided as this can precipitate an acute myocardial infarction and sudden death.

Introduction

• Wellens syndrome is characterized by a classic ECG pattern indicative of imminent anterior myocardial infarction (MI), often suggesting a critical left anterior descending (LAD) artery stenosis.
• This is an important syndrome for emergency and acute care physicians, as early recognition can be life-saving.

Aetiology

• Usually indicates > 90% stenosis in the LAD, which is often critical and requires prompt intervention to prevent MI.

Pathophysiology

• Atherosclerotic Plaque: Wellens syndrome typically results from a high-grade atherosclerotic plaque in the LAD, which leads to transient occlusion or reduction in blood flow.
• Coronary Artery Vasospasm: Intermittent spasms in the LAD may also contribute to ischaemic episodes.
• Increased Cardiac Demand: Physical or emotional stress can increase oxygen demand, exacerbating ischaemia in an already compromised LAD.
• Hypoxia: Reduced oxygenation can worsen ischaemia, especially in a critically narrowed LAD.

Risk Factors

• Diabetes mellitus
• Family history of premature heart disease
• Hypertension
• Advanced age
• Hypercholesterolemia
• Hyperlipidemia
• Metabolic syndrome
• Occupational stress
• Smoking

Clinical Presentation

• Often presents as chest pain, breathlessness, or angina-like symptoms.
• May be asymptomatic at presentation, making ECG changes vital for diagnosis.
• Anginal equivalents such as jaw or arm pain may also be present.

Investigations

• Blood Tests: FBC, U&E, LFTs
• Troponin: May be elevated but not always markedly.
• ECG:
  • Biphasic or deeply inverted T waves in V2-V3, occasionally extending to V1-V6, suggesting significant LAD stenosis.
  • With progression to full LAD occlusion, T waves may normalize and become hyperacute, signifying imminent STEMI.
• Echocardiogram: Can assess heart function and look for wall motion abnormalities.
• Coronary Angiography: Necessary for definitive diagnosis and evaluation of LAD stenosis.

Management

• Immediate Care: ABCs, oxygen as required, admit to CCU, start nitrates, aspirin or clopidogrel, and beta-blockers.
• STEMI Protocol: If ST elevation develops, treat as an acute STEMI.
• Angiography and Revascularization: Given the high likelihood of critical LAD stenosis, most patients will require angiography, and possibly percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG), depending on the disease severity and patient factors.
• Avoidance of Stress Testing: Stress testing is contraindicated due to the risk of precipitating an acute MI or sudden cardiac arrest.

Prognosis and Clinical Significance

• High Risk of MI: Wellens syndrome is associated with a high risk of anterior MI if not managed appropriately and urgently.
• Timely Recognition: Early identification and intervention can significantly improve outcomes and prevent complications.
• Long-term Management: Risk factor management, including blood pressure and cholesterol control, smoking cessation, and diabetes management, is essential for reducing recurrence.

References

• Wellens Syndrome