ICE 016 Delayed presentation chest pain • LITFL • ICE Clinical Cases

The previous evening, a 59 year old man experienced an hour long episode of chest pain which resolved spontaneously. He has had no further chest pain, but encouraged by his family he presents to ED the next morning. A bedside cardiac troponin test is negative. This is his ECG taken at the same time.

Questions

Describe his ECG
What do the ECG findings signify ?
How should this patient be managed?

Reveal the ICE answer

The ECG shows sinus rhythm at 60 /minute, with abnormal ST/T wave changes in V1 through V5 but most marked in leads V2, V3 & V4. There are biphasic T waves in V2 & V3 with the negative component of the T wave being deeply so. In V4 there is very deep T wave inversion.

These particular ECG findings are called a Type 1 Wellens’ pattern. (The other and more common Type 2 Wellens’ pattern with only deep T inversion in V2 – V4 is shown in the ECG underneath this answer) Wellens’ pattern ECGs very likely signify severe stenosis of the left anterior descending coronary artery. They were only first described as an ECG syndrome in the early 1980s and named after the author of the first publication on it. At other times it has been called Wellens’ sign or Wellens’ warning. The last name emphasises the usual clinical course, which is to progress to full occlusion and a completed anterior infarct unless intervention occurs.

This patient should be admitted, not sent for outpatient follow-up. Stress testing should be avoided as it may precipitate a completed infarct. Antiplatelet agents and heparin should be commenced but the key intervention is early coronary angiography/angioplasty.