Transmural Myocardial Infarction Without ST Elevation—Wellens Syndrome as an ECG Emergency

Figure

The anterior wall leads from a 12-channel ECG (25 mm/s, 10 mm/mV) with Wellens type A pattern. Main findings: biphasic, symmetrically inverted T-wave in V3 and 4, no significant ST-segment elevation. Red area: initially positive portion of the T-wave. Green area: subsequent negative, symmetrically inverted portion of the T-wave. This combination is specific to the Wellens type A pattern. In contrast, the Wellens type B pattern would show deeply inverted T-waves in the anterior chest wall leads (V2/3). There is also complete right bundle block and a non-significant STsegment elevation in V2.

A 59-year-old man presented to the emergency department with unstable angina pectoris for the past few hours and a hypertensive crisis (180/100 mm Hg). The heart rate was 79 beats/min in sinus rhythm. The patient was known to have arterial hypertension and right bundle block. The 12-lead ECG trace was abnormal (Figure). The troponin T concentration was 0.286 μg/L (reference: < 0.01 μg/L), the CK level 581 U/L (reference: < 145 U/L). Coronary angiography showed one-vessel coronary artery disease with acute proximal occlusion of the left anterior descending artery. Following revascularization, the patient was discharged on day 6 of treatment in good general condition. Terminal negative T-waves in the chest wall leads remained as ECG residuals after coronary intervention. The patient had an acute anterior wall infarction. Around 25–30% of myocardial infarctions with vascular occlusion do not involve ST-segment elevations. Just like ST-elevation infarctions, however, they require immediate reperfusion. The Wellens type A pattern, even without ST elevations, indicated the presence of critical stenosis/occlusion of the left anterior descending artery. Patients can be symptom-free or have fluctuating symptoms; early recognition of the ECG findings is important. Together with a compatible clinical presentation, this ECG pattern should prompt coronary angiography with no delay.

Dr. med. Sascha Macherey-Meyer, PD Dr. Matti Adam, Dr. med. Victor Mauri, Universität zu Köln, Medizinische Fakultät und Uniklinik Köln, Klinik III für Innere Medizin, [e-mail]

Conflict of interest statement: The authors declare that no conflict of interest exists.

Translated from the original German by David Roseveare.

Cite this as: Macherey-Meyer S, Adam M, Mauri V: Transmural myocardial infarction without ST elevation—Wellens syndrome as an ECG emergency. Dtsch Arztebl Int 2023; 120: 890b. DOI: 10.3238/arztebl.m2023.0107