Sunday, March 20, 2011

Classic Evolution of Wellens' T-waves over 26 hours

t = 0, presentation to ED: Initial ECG of 50 yo woman who had prehospital chest pain, now resolved.  There is old inferior MI (and the nonspecific minor T inversion in aVL may be due to this, or may be new) but precoordial leads are unremarkable.

t = 1.83 hours. There are now the beginnings of T-wave inversion in aVL, V4 and V5.

t = 4.75 hours.  Now there is the beginning of T-wave inversion in V2, with more in V3, and progressive T-wave inversion in aVL, V4, and V5.

 t = 6 hours.  Still more T-wave inversion, becoming symmetrical in V4 and V5.

t = 8.5 hours.  Still more T-wave inversion and increasing symmetry.
t = 23 hours.  Deepening T-waves with increasing symmetry.

t = 27 hours.  Diffuse symmetric T-wave inversion.  The patient had positive troponins and a tight LAD stenosis that was stented.


  1. Hi Dr. Smith...
    thank you again for the fascinating post...
    during this evolution, there appears to also be a progressive lengthening of the QTc, presumably due to the widened and deepened T waves... is a lengthening QTc a consistent finding with developing Wellens'?

  2. You're paying attention. In fact, in my experience (though I know of no studies addressing this), the QT is prolonged in Wellens'. This is one way to differentiate it from benign T wave inversion (BTWI), which usually has a QTc < 400-425 (as do most forms of early repolarization). I will post an example of BTWI soon. In this series, the computerized QTc's were, respectively: 429, 419, 438, 428, 476, 520, 511.