Tuesday, June 17, 2014

Wellens' waves appear and disappear again and again, all troponins negative: Unstable Angina

This middle-aged woman presented with increasing intermittent substernal chest discomfort similar to her GERD, but not relieved by the usual therapies.  She was given an aspirin.  She had the following ECG recorded in the ED:
A very astute physician read this as "biphasic T-waves in V3 and V4."  There is also T-wave inversion in aVL.  This is very suggestive of Wellens' syndrome with a proximal LAD lesion.

A subsequent ECG was recorded:
Not much changed

The patient was admitted to observation.  Her troponins [Ortho Clinical Diagnostics, Limit of detection is 0.012 mcg/L, 99% reference value ("positive" troponin) of 0.034 mcg/L] were less than 0.012, then 0.015, then less than 0.012.  Since these are all below the 99% reference, and thus they are technically "negative;" however, a detectable rise and fall is suggestive of unstable angina.

The ECG findings were not commented upon by the inpatient team, and the patient technically "ruled out" for MI.  After a careful evaluation that did not suggest an ischemic etiology, she was sent home without doing a stress test and with a diagnosis of "reflux."

2 weeks later, the patient presented with the same symptoms, happening 5 times between 6 AM and noon, never lasting longer than 15-20 minutes.  Here was here initial ECG:
This time there are full blown Wellens' T-waves in V2-V5, I, and aVL, nearly diagnostic of a proximal LAD stenosis.  When the patient has pain, it is likely that the artery is briefly closing.

25 minutes later, this ECG was recorded:
There are PVCs, but the Wellens' T-waves have resolved.  This is typical of unstable angina: when there is infarction, the T-waves will evolve by becoming deeper and more symmetric over many hours' time.  See link below.

She was started her on heparin and eptifibatide.  105 minutes later (it is uncertain whether the patient had another episode of pain that she did not report). 
Wellens' waves are back

The next day at 7 AM this was recorded:
Wellens' T-waves are again less prominent


Troponins never became "positive:"  The first level was "normal," the second was "normal," then 3rd was 0.021, 4th 0.029, 5th 0.032, never climbing above the 99% reference value of 0.034 mcg/L.

Later that day, the patient underwent an angiogram and had a 95% stenosis of the proximal LAD with thrombus, and another of the first diagonal off the LAD.  Both were stented.

This is an unusual case of "Wellens' syndrome."  The amount of myocardial infarction (necrosis), as measured by troponin, was so small that the T-waves did not have the typical evolution (T-waves become deeper and more symmetric) seen here:

http://hqmeded-ecg.blogspot.com/2011/03/classic-evolution-of-wellens-t-waves.html

Instead, the T-waves were dynamic, inverting, then normalizing.  One might be tempted to call these normalizing T-waves "pseudonormalization."  But this term is the name for the becoming-upright of a T-wave when the artery is re-occluding.  See these posts:
http://hqmeded-ecg.blogspot.com/search/label/pseudonormalization

In this case, the ischemia is resolving without significant infarction, so that the T-waves truly normalize.

1) Even ACS with negative troponins may be strongly suspected by ECG analysis.
2) Troponin rise and fall, even below the 99th percentile, strongly suggests ACS
3) Dynamic T-waves are an infrequent but potentially important sign of ACS.



7 comments:

  1. Nice case. Thank you. Were there also some parietal hipokinesia ? Very low troponin , could be explained by ischemic cascade? Do you use eptifibatide up-stream?

    ReplyDelete
    Replies
    1. Alenia, I occasionally use eptifibatide upstream if it is very high risk (like Wellens' is) AND the patient is not going immediately to cath. I'm not sure what you mean by "parietal hipokinesia" or "ischemic cascade". The low troponin indicates a very small amount of myocardial necrosis, but does not meet the standard definition of MI (at least one value above the 99th %ile.).
      Steve Smith

      Delete
    2. send to: dr.smiths.ecg.blog@gmail.com Two things help it get posted: 1) it must be unique, interesting, accurate, 2) the more finished the product, the less work I have to put into it. My time is very limited and I can't put up as many posts as I would like, though I have endless material

      Steve Smith

      Delete
  2. Alenia,
    I use eptifibatide in very high risk patients (like Wellens') who are not going immediately to cath. The low troponins were due to very small amount of ischemic cellular infarct (necrosis, death), but were not high enough to meet the standard definition of MI, in which at least one value must be above the 99th %ile.
    Steve Smith

    ReplyDelete
  3. What if someone want to contribute to this blog ? or to send ecgs.
    Regards

    ReplyDelete
  4. Dear dr. Smith,

    On a side note, is it true that 'inferior wellens' suggests near coronary occlusion of RCA/RCx? Thought you mentioned this in one of your blog posts, but I could'nt find it.

    Kind regards,
    Emil

    ReplyDelete
    Replies
    1. Emil,
      Yes. I call them reperfusion T-waves. They signify previous occlusion with spontaneous reperfusion, at which time the T-waves turn down. This is the pathyphysiology of Wellens and it occurs in any coronary distribution.
      Steve

      Delete

Recommended Resources