Author: Lloyd Tannenbaum, MD (EM Attending Physician, APD, Geisinger Wyoming Valley, PA) // Reviewer: Brit Long, MD (@long_brit)
Hello and welcome back to ECG Pointers, a series designed to make you more confident in your ECG interpretations. This week, we feature a post from Dr. Tannenbaum’s ECG Teaching Cases, a free ECG resource. Please check it out. Without further ado, let’s look at some ECGs!
“But he has no pain now! Why are we admitting him? Can’t I just discharge him?” you hear your resident ask you for the third time.
“Look!” you say, a little more sternly than intended and then take a deep breath, “Look at Mr. Johnson and his ECG again and tell me what you see.”
“Well, I see a patient sitting in the stretcher, telling me that he had chest pain 2 hours ago but it’s resolved. His ECG shows normal sinus rhythm with some nonspecific ST-T wave changes. He can go home. He can follow up as an outpatient with cardiology. I feel like when I work with you, you admit everyone. All the other attendings would let me discharge him.”
You take a deep breath and remind yourself that it’s a privilege to assist young doctors in their quest for knowledge, even the ones that seem immune to learning or maturity. “Young one, come over here, let’s look over this ECG together and then maybe you’ll understand where I’m coming from.” You see the resident roll his eyes, but walk over to you to review the ECG:
Rate: 80 ish
Rhythm: Normal sinus
Axis: Normal
Intervals: Normal PR interval, narrow QRS complexes, QTc looks reasonable
Morphology: There is some non-specific ST-T wave changes present, like the T wave inversions in I, aVL, II, V4/V5 or the T wave flattening in aVF, V6, but the most concerning part of this ECG are the Biphasic T Waves present in leads V2 and V3
Final Read: This ECG shows normal sinus rhythm with biphasic T waves in V2 and V3 (which we’ll discuss below).
“Ok, tell me about those T waves in V2 and V3,” you ask your resident.
“Well, they’re biphasic. They have a positive deflection from the baseline and then dive down under the baseline before coming back to it. But, so what? Isn’t that just a non-specific finding? Why should we care about weird T waves? Can’t we just move on to the next patient?”
“Correct,” You respond, “But tell me more about his story. What brought Mr. Johnson into the ER today?”
“Fine. I’ll give you the full presentation again. Mr. Johnson is a 67 year old male with a history of diabetes, hypertension, hyperlipidemia, and an active smoker who comes to the ER for chest pain. He states that he was in his normal state of health until he was out walking his dog. They took a longer walk than normal and as they were finishing, he felt intense pressure in his chest. He was sweating and felt like he was going to vomit. He’s had panic attacks in the past and thinks this was just another panic attack. He called EMS and they gave him aspirin and nitro and brought him here. After resting, he feels fine, the pain is gone and he wants to go home. His troponin is negative; we can let him go!”
“Let me tell you a quick story. Take a look at these ECGs (below). I’ll tell you more about them in a second, but walk me through what you’re seeing:”
“So,” your resident tells you, “ECG A shows you a tracing that looks mostly like normal sinus rhythm with some nonspecific ST-T wave changes. ECG B shows you some abnormal looking T waves that don’t meet STEMI criteria. V2 and V3 look biphasic. Finally, ECG C shows an anterior STEMI!”
“Correct. Now let me tell you about this patient. These ECGs come from Dr. Wellens original paper (link here[Characteristic electrocardiographic pattern indicating a critical stenosis high in left anterior descending coronary artery in patients admitted because of impending myocardial infarction – PubMed]) where he noted a concerning ECG patterns indicative of high grade, proximal stenosis of the Left Anterior Descending (LAD) coronary artery. ECG A was obtained upon arrival to the ER from a 45-year-old male with exertional chest pain. His story was concerning for acute coronary syndrome, so he was admitted to the hospital. ECG B was obtained 23 hours after admission. The patient had no pain and had normal lab markers at that time. Over the next 3 days, His ECG returned to normal and he was discharged. 9 days after his admission, he returned to the hospital with severe chest pain and ECG C was recorded. The patient then went into cardiac arrest and could not be revived.”
You see your resident’s eyes start to get a little bigger as he begins to pick up on what you are saying.
“Now let’s take a look at the results from his initial paper. Take a look at this table:”
“Now let’s work through this together. This table comes from 26 patients who were admitted for unstable angina and had the ECG pattern consistent with Wellens Syndrome. Notice that right at patient 9, there is a drastic change from patients having an acute MI and patients going to the cath lab? Well, if you’re thinking that this is when the cardiologists at Dr. Wellens’ hospital realized the significance of the pattern of ECG B, you’re correct. Once they realized that this was a sign of impending LAD occlusion, early cath was offered to these patients (within 4 days of admission). 10 accepted, 5 refused, and 2 were deemed too old for PCI. Of those 10 that were cath’ed, 9 had significant coronary artery disease and all 9 had significant (>90%) stenosis of the LAD. Many of these patients required a coronary artery bypass graft (CABG) and all of those that underwent CABG required a graft to their LAD.”
“Be aware, there are two different patterns (Wellens Type A and Type B) that you need to be on the lookout for. Here are examples of each, from Dr. Wellens’ initial paper:
Image citation: de Zwaan C, Bär FW, Wellens HJ. Characteristic electrocardiographic pattern indicating a critical stenosis high in left anterior descending coronary artery in patients admitted because of impending myocardial infarction. Am Heart J. 1982 Apr;103(4 Pt 2):730-6. doi: 10.1016/0002-8703(82)90480-x. PMID: 6121481
Notice how in Type A you see biphasic T waves in V2/3, very similar to the T waves in Mr. Johnson’s ECG. And in Type B you see broad, symmetric, inverted T waves, often seen in V1-V4.” Type B is more common than Type A.
“Finally, take a look at this figure below. It’s from Dr. Wellens’ follow up article in 1989 that looked at 180 patients with his pattern on ECG:
Notice how medical therapy alone was not the optimal treatment for these patients (30% had an MI, 27% died!).”
You look over and notice that your resident seems to be a bit embarrassed and is taking Mr. Johnson’s case much more seriously now. He tells you, “I see the Wellens patter in his ECG now, maybe we shouldn’t discharge him after all…”
“Ok, I’ve beaten up on you enough today,” you tell him. “Let’s do a quick recap on Wellens Syndrome so you can call cardiology and discuss this patient with them.
Quick Review:
- There are two ECG patterns to be aware of with Wellens Syndrome, Type A and Type B
- Type A classically shows biphasic T waves in V2 and V3
- Type B shows deeply inverted T waves, often in the anterior leads (V1-V4)
- Type B is more common than Type A
- These patients will often present with anginal chest pain and may have a cardiac history
- Often, they will be chest pain free!
- Do not be lulled into a false sense of security!
- Don’t be surprised if their cardiac biomarkers are negative or only minimally elevated
- Again, do not be lulled into a false sense of security!
- Be on the lookout for these patterns. They will show up and these patients need a cath sooner than later!
- These patients need a cath, not a stress test! Stress imaging could be fatal.
