EKG of the Week 2016 11-13

This EKG comes courtesy of Dr. Braden Fichter.

A 45 y/o male presents to the ED complaining of chest pain. He describes it as “I feel like I got kicked in the chest”. Vital signs are within normal limits. His EKG is below.

1.    What does the EKG demonstrate?

2.    How would you manage this patient?

 

ANSWER:

The EKG demonstrates a Wellen’s sign.

Patients with a Wellen’s syndrome should be managed aggressively for acute coronary syndrome with early catheterization.

The EKG demonstrates biphasic T waves in leads V2-V5 as well as T wave inversions in leads V5, V6, I and aVL.

Wellen described EKG changes suggestive of a proximal LAD occlusion and a 75% risk of anterior wall MI. Wellen’s sign consists of a minimally elevated takeoff of the ST segment from the QRS complex, a concave or straight ST segment and a symmetrically inverted T wave in leads V1-V3. Some patients can have findings extend out to lead V4 or even V5 and V6.

Patients with symptoms of unstable angina and these EKG findings are said to have Wellen’s syndrome. They have a high risk of having an anterior wall MI in the next few weeks due to a critical proximal LAD stenosis. These patients need early cardiac catheterization.

Our patient had an initial troponin of 1.7. He went to cath and was found to have a 99% mid LAD occlusion.

 

For additional information, see: http://accessemergencymedicine.mhmedical.com/MultimediaPlayer.aspx?MultimediaID=12385306&SearchTerm=Wellen%27s

(Reference: de Zwaan et al. Characteristic Electrocardiographic Pattern Indicating a Critical Stenosis High in LAD in Patients Admitted Because of Impending Myocardial Infarction. Am Heart J 1982;103:730-6.)