Tuesday, January 12, 2010

Anterior pseudonormalization

A 68 year old male with no previous h/o MI presented after 2 weeks of exertional dyspnea. On the day of presentation, he was shoveling snow and experienced 30 minutes of chest pressure and a sense of doom, which was resolved upon arrival. He had had a negative stress sestamibi 3 months prior.

There is abormal deep T wave inversion in anterior leads suggestive of Wellens' syndrome, although true Wellens' should have better R-wave preservation. This ECG is diagnostic of MI, but is not a STEMI. Though this has never been explained or studied in the literature, it is clear to me that Wellens' is the consequence of a spontaneously reperfused STEMI. The Wellens' ECG is identical to the ECG of patients who reperfuse MI with fibrinolysis or PCI. Wellens' is always in a pain-free patient and the angiogram always shows tight LAD lesion with either good flow or collateral flow.

35 minutes later his son reported that he had a "funny feeling" and "tightness in the throat;" at the same time the initial troponin returned positive at a low level. A repeat ECG was recorded:

Now the T-waves are upright (not normal, but "pseudo"normal). This is indicative of re-occlusion. Where Wellens' is spontaneous reperfusion, pseudonormalization is spontaneous re-occlusion of a Wellens' syndrome.

This patient had an LAD occlusion.


  1. Fantastic example of the dynamic nature of ACS!
    Jorge Brenes, MD

  2. Hey Steve,
    Do you think the absence of well-developed R waves here are a result of this acute Wellen's phenomenon-- on top of the presence of a previous anterior MI?

    1. Sam,
      Yes, he had a previous MI and has superimposed T-wave inversion and pseudonormalization.


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