The pain came on at rest and lasted 30 minutes. She is pain-free in ED. She’s had chest pain on exertion for three months, for which she takes GTN. She has no other past medical history and is a life-long non-smoker. She looks well and examination is normal.
Here are two ECGS:
Top: Pre-hospital ECG
Bottom: ED ECG (Pain Free)
1. What clinical syndrome does the ECG show?
- Wellens' syndrome, also known as LAD (Left Anterior Descending Artery Syndrome).
- The Left Anterior Descending artery supplies a large part of the left ventricle with blood.
- The patient usually presents with cardiac chest pain. Risk factors may be minimal.
- The ECG may be normal when the patient is experiencing the pain, but then becomes abnormal after the pain has settled.
2. What is the underlying pathology?
- There is a proximal stenosis in the left anterior descending artery.
- Angiography in these patients shows there is at least a 50% stenosis of the LAD in these patients, so it’s a high risk lesion.
3. What variations of this syndrome exist and what are the typical ECG changes?
- There are two typical changes on the ECG:
- The majority (75% of patients) will have inverted T waves in leads V1-V4
- In the remainder, the T waves are biphasic (go up and down) in leads V2-V3
4. How would you manage this patient?
- This patient is at high risk of having a myocardial infarction. (Most patients with this syndrome progress to myocardial infarction within 8 days and as the LAD is also called ‘The Widow-maker’, this is a diagnosis not to be missed.
- They need to be admitted.
- Don’t rely on the troponin – it is often normal in this condition!
- Ensure that the patient has had 300mg aspirin.
- They will need urgent angiography and therefore it is worth discussing them with the cardiology registrar on call who will advise on the use of clopidogrel/LMWH and where the patient should be sent to (CCU versus CDU).
5. What investigation should this patient NOT have done?
- This patient should not have an exercise tolerance test as this can lead to myocardial infarction.