Sunday, March 20, 2011

Classic Evolution of Wellens' T-waves over 26 hours

A middle-aged patient presented with resolved chest pain.

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).  
There is subtle ST elevation in V2 and V3 with reverse R-wave progression and subtle ST depression in V5 and V6.  
This ST elevation should not automatically be attributed to normal variant early repol because there is also reverse R-wave progression and the afore-mentioned STD in V5 and V6, neither of which occur with normal variant ST elevation.
Therefore, this is suspicious for resolving LAD occlusion.

Serial ECGs are critical, especially if chest pain persists or recurs. 

The patient remained pain free, and did not get another ECG for 110 minutes:
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.

  3. Is the STD in V5-V6 unremarkable?
    And the near isoelectric T-wave?

  4. of course in T0 (1st. ecg)

    1. You are absolutely right. In fact, all the precordial leads suggest subtle LAD occlusion, or resolving LAD occlusion. There is ST elevation with reverse R-wave progression in addition to subtle STD in V5, V6.

  5. Thx for serial ECG!
    It should be taught for patients in all university! :-)
    Lancelot (from Hungary)

  6. Very interesting and informative serial ECGs, I also found that the prolonged QTc due to widened and deepened T wave, So Can we use beta blocker agents to treat the ischemia, sir? Are beta blocker agents contraindicated in this situation because it can make the QTc prolong, sir?

    1. the problem is a "hot" ulcerated plaque. Beta blockers won't help that. Antiplatelet and antithrombotic agents.


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