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J Gen Intern Med. 2015 July; 30(7): 1035–1036.
Published online 2015 February 27. doi:  10.1007/s11606-015-3251-4
PMCID: PMC4471017

Wellens’ Syndrome in an Elderly Patient with Dementia

A 90-year-old woman with a history of dementia experienced acute-onset chest pain, dyspnea, and nausea at rest. In the emergency department, she was asymptomatic, with stable vitals, negative troponin T, and ECG non-indicative of myocardial infarction (MI) (Fig. 1). The next morning, she developed severe chest pain, and ECG revealed ST elevation in V1–V4 (Fig. 2). Her troponin T level peaked at 3.56 ng/ml. An echocardiogram showed an ejection fraction of 35% with akinesis of the antero-septum, apex, and distal anterior wall, consistent with left anterior descending (LAD) artery infarction. Her family declined percutaneous coronary intervention after learning of the associated risks, including contrast-induced nephropathy.1 Reconsideration of her initial ECG revealed a less common variant of Wellens’ Syndrome: biphasic T waves in leads V1–V3.2,3 The more common pattern is deep, symmetrically inverted T waves in leads V2 and V3 (or other precordial leads), often during a chest pain-free interval.2,4,5 Wellens’ syndrome has been found in up to 14% of patients with unstable angina whose angiograms showed a mean LAD stenosis of 85%.6 Recognition of Wellens’ syndrome is important, because these subtle ECG patterns are associated with impending extensive anterior wall MI in up to 75% of patients.2,4

Fig. 1
Initial ECG with biphasic T waves in leads V1–V3, a less common variant of Wellens’ Syndrome
Fig. 2
ECG 12 hours later showing ST segment elevation in leads V1–V4

Conflicts of interest

All authors contributed to the preparation of this manuscript. We have no conflicts of interest to disclose or any financial disclosures to report.

References

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6. de Zwaan C, Bär FW, Janssen JH, et al. Angiographic and clinical characteristics of patients with unstable angina showing an ECG pattern indicating critical narrowing of the proximal LAD coronary artery. Am Heart J. 1989;117(3):657–65. doi: 10.1016/0002-8703(89)90742-4. [PubMed] [Cross Ref]

Articles from Journal of General Internal Medicine are provided here courtesy of Society of General Internal Medicine