Home /

Wellens Syndrome

Wellens syndrome (critical stenosis of the left anterior descending artery - LAD)

Wellens' Syndrome

• Wellens and De Zwann described it in 1982
• in patients with unstable angina pectoris
• atypical T waves in leads (V2-V3)
• Within one week, these patients developed anterior STEMI
• These patients had critical proximal stenosis of the LAD
• Chronic or acute
• Wellens' Syndrome
• Is a pre-infarction (precursor of infarction)
• 75% of patients will develop anterior STEMI
• On the ECG, it shows atypical T waves (V2-V3)
• It is present in 15% of patients with unstable angina pectoris
• Patient should not undergo ergometry (stress test ECG)
• During ergometry, the patient could experience an infarction
• The patient must receive a stent in the proximal LAD

ECG and Wellens' Syndrome (Type I)

• Symmetrical deep negative T waves (V2-V3)
• which descend almost vertically downward
• Minimal ST elevations < 1mm
• No Q wave (V1-V6)
• Progression of R wave is preserved
• ECG changes occur while the patient is asymptomatic

Windowmaker Artery

• Refers to
• critical stenosis or occlusion of the proximal LAD (left anterior descending artery)
• Critical stenosis of the proximal LAD
• Is Wellens' syndrome
• The patient will experience anterior STEMI within one week
• Occlusion of the proximal LAD
• Is acute anterior STEMI
• 2% of patients with acute proximal LAD occlusion
• Present with De Winter T waves
  
  
• Windowmaker artery has a very poor prognosis

Windowmaker Artery

• The patient had Wellens' syndrome (Type I) on the ECG
• Symmetrical deep negative T waves (V2-V3)
• 75% of these patients will experience anterior wall STEMI within a week
• The patient was subjectively asymptomatic
• Only experienced recurrent chest pain at home
• Coronary angiography revealed 95% stenosis of the proximal LAD
• Proximal stenosis (or occlusion) of the LAD is referred to as the windowmaker artery

Recanalization of LAD

• After stenting, the proximal LAD is completely recanalized
• The patient has a physiological ECG
• Repeated chest pain has resolved

Pseudo-normalization of T Waves and Wellens Syndrome

• Wellens syndrome primarily occurs in patients with chronic stenosis of the LAD (atherosclerosis)
• During an atheroma rupture, occlusion of the LAD occurs
• A STEMI of the anterior wall begins to develop (Patient experiences chest pain)
• This stage cannot be captured on EKG
• Later, the LAD spontaneously recanalizes (within minutes)
• (due to aspirin use, spontaneous thrombolysis)
• After recanalization of the LAD
• The stenosis is greater than before recanalization
• The patient now has critical asymptomatic LAD stenosis
• Patient is symptom-free
• 75% of patients will experience a STEMI of the anterior wall (LAD occlusion) within one week
• At this stage, the patient will show Wellens syndrome (V2-V3) on EKG
• Patient is symptom-free
• Pseudo-normalization of T Waves and LAD Re-occlusion
• The patient is symptom-free and has Wellens syndrome on EKG (negative T waves V2-V3, very rarely V1-V6)
• If the patient experiences LAD re-occlusion, then STEMI of the anterior wall will begin to develop
• Patient experiences chest pain
• Hyperacute STEMI results in high T waves
• Hyperacute STEMI (high T waves) in the context of Wellens syndrome (deep T waves)
• Creates normal T waves - T waves normalize (this is pseudo-normalization)
• Because hyperacute T waves developed in the context of negative T waves (Wellens syndrome)
• LAD Occlusion
• If LAD occlusion persists
• After the hyperacute phase, classic STEMI EKG dynamics follow

De Winter T Waves and Wellens Syndrome

De Winter T Waves

• Refers to proximal LAD occlusion
• Patient has angina (chest pain)
• Considered an equivalent of STEMI

ECG and De Winter T Waves

• Changes are in V1-V6
• Symmetrical high T waves
• Ascending ST depressions
• (De Winter T Waves)

Wellens Syndrome

• Refers to critical proximal LAD stenosis
• Patients do not have angina
• STEMI will develop within a week

ECG and Wellens Syndrome

• Changes are in V2-V3
• Wellens Syndrome has 2 types:
• Symmetrical deep T waves (Type I)
• Bifid T waves (Type II)

Wellens Syndrome (Type II)

• Bifid T waves (V2-V3)
• The first part is positive, the second part is negative
• Minimal ST elevations < 1mm
• The progression of R wave (R in V3 > 3mm) is preserved
• Patient has asymptomatic critical proximal LAD stenosis
• 75% of patients will develop anterior STEMI within 7 days

Wellens Syndrome (Type I)

• Symmetrical deep negative T waves (V1-V6, aVL, I)
• Changes may be rare (V1-V6), but most commonly observed in (V2-V3)
• The progression of the R wave (R in V3 > 3mm) is preserved
• Patient has asymptomatic critical proximal LAD stenosis
• 75% of patients will develop anterior STEMI within 7 days
• Left anterior fascicular block