Anything but Well : Wellen Syndrome Turning into Acute Myocardial Infarction .
Christopher Sheng, Alzamani Idrose
Emergency Department, Hospital Kuala Lumpur
Wellen syndrome is critical stenosis of the left anterior descending artery (LAD). T-waves present in precordial leads especially V2-V3 when ECG performed during pain-free periods in a patient presenting with chest pain. 75% of Wellen syndrome patients is reported to develop acute anterior wall myocardial infarctions (MIs) within one week if no intervention is carried out. Despite its significance, the diagnosis can still be missed .
50 year old gentleman ,having no comorbids apart from smoking for the past 33 years , presented to emergency department with central chest pain for two days . He has smilar pain a month ago. However upon arrival he was pain-free . He was haemodynamically stable , and was given early treatment as per ACS protocol . ECG findings were deep T inversions at V2- V4 . Trop T rose from 44 turn in to 227. Initially he was treated as NSTEMI patient was sent from medical ward to Coronary Rehabilitation Ward. In view of the ECG pattern, he was diagnosed as having Wellen syndrome and referred to Cardio center for urgent angiogram. Nevertheless, patient's transfer was put on hold in view of being stable and pain-free. Unfortunately, the next morning patient suddenly developed suddent chest pain and the repeated ECG showed ST elevation of V2 to V6 . Patient was given sublingual GTN and repeated ECG however showed resovled ST elevation. Patient was then transferred to the cardiac centre and the PCI done confirmed stenosis on proximal LAD and stent was inserted.
Wellen syndrome very high risk turn into Acute Anterior wall Myocardial Infarction within days to weeks. It is therefore important to be monitor closely , and to refer for urgent angiogram intervention as soon as possible . In this patient, early nitroglycerin was noted to revert the ST elevation caught early on ECG monitoring. It was likely that the left anterior descending artery dilated and prevented further myocardial ischaemia causing the ST elevation resolution. With a prompt PCI , patient LAD stenosis was taken care off
Prompt recognition of Wellen syndrome is the best way to avoid mortality and morbidity in this group of patient as we have a short window to help them. Furthermore, our case showed early nitroglycerin helped to revert the ST elevation and perhaps reversal of coronary blockage when given early.