Case of the Month 1.2012

Submitted by Jacob Gessin, MD

CC: CHEST PAIN, BACK PAIN and ABNORMAL EKG

HPI: Patient is a 70 yo F with a history of HTN and Hyperlipidemia who was sent in from clinic for an abnormal ECG showing T-wave inversion in the precordial leads after the patient went to clinic for light-headedness during Tai-Chi today. The patient reports having “indigestion” today and back pain for 2 days. Indigestion feels like “acid” in her throat. It is uncomfortable but not painful. Back pain is around the left shoulder radiating to the right, it feels like a “knot”. It is 5/10 in severity. It is constant, no exacerbating factors. Ibuprofen helps the pain. Light-headedness with TaiChi today was just “momentary” and it resolved when the patient sat down. The patient admits to having a “dull” chest pain 2/10 in severity that lasts for seconds and then resolves, which has only occurred in the ED during the H&P. The patient denies shortness of breath, nausea, vomiting, diaphoresis or palpitations.
Denies tobacco or drug use.
Family history: non-contributory.

EKG done at triage:

Repeat EKG done 15 minutes after arrival:

What do you do now?

A) Nothing. Send the patient home. She is largely asymptomatic.
B) Give the patient aspirin and admit to the obs unit.
C) Call the interventionalist on call and plan to transfer the patient for emergent catheterization.

Answer:

C) Call the interventional cardiologist and plan to transfer the patient for emergent catheterization. The first EKG shows what is known as Wellen’s syndrome and is highly suspicious for a critical LAD lesion.

ED Course:

The patient was transferred emergently to the cath lab where she was found to have 100% occlusion of the mid LAD. She underwent successful stenting of the lesion. Her initial troponin drawn on arrival was found to be 0.05.


Key points:

1. The importance of serial EKG’s and dynamic EKG changes.
2. ACS in elderly and females can present subtly.
3. EKG showing Wellen’s Syndrome.

Wellen’s Syndrome:

From: Life in the Fast Lane:  An ECG abnormality strongly associated with significant left anterior descending coronary artery stenosis.There are 2 types of Wellens syndrome:

More detailed crieteria for the diagnosis of Wellens’ syndrome:

    • Either of the 2 T wave abnormalities described above.
    • History of chest pain.
    • Normal / minimally elevated cardiac enzymes.
    • No pathological Praecordial Q waves.
    • Minimal / no ST elevation.
    • No loss of praecordial R waves.

First described in 1982 by Professor Hein J. J. Wellens. This syndrome has, along with Brugada Syndrome, become one of the essential instant recognition abnormalities on ECG for Emergency Physicians. The significance of it in a population that could otherwise be sent home from the emergency department is that stress testing as part of your further risk stratification is probably a bad idea. This ECG pattern is strongly associated with a widow maker lesion – with 100% of 180 patients with the pattern having >50% stenosis of the left anterior descending coronary artery (mean = 85%), with complete or near complete occlusion in almost 60%.

Stress testing may prove fatal as there is usually minimal collateral circulation to a large part of the anterior myocardium. Once identified these patients need urgent / emergent angiography and intervention.


Biblio:

  1. de Zwaan C, Bär FW, Janssen JH, Cheriex EC, Dassen WR, Brugada P, Penn OC, Wellens HJ. 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 Mar;117(3):657-65.
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