Wednesday, May 4, 2011

Wellens' missed. Then returns with Wellens' with dynamic T-wave inversion

This 53 year old 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:
There is now a bit less of the biphasic T-waves.

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".  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; usually when there is significant 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 (uncertain whether the patient had another episode of pain that she did not report), the Wellens' T-waves were back.
Wellens' T-waves return

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, 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:

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:

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.
4) Unstable Angina is alive and well!  Troponins do NOT rule out ACS.


  1. Thanks for a great post. On the first ecg, there is also T wave inversion in AVL besides for the Wellenoid pattern T waves.
    T wave inversion in AVL. This link may prove useful, although further studies may be warranted.
    In this patient there was an LAD lesion... makes us think!

    Kindest regards
    Sa'ad Lahri
    Cape Town

  2. And interestingly - the ST-T wave changes in lead aVL evolve as do the precordial changes (also a small q in lead aVL) - AND - I believe there may be a hyperacute T wave in lead V2 in the 4th tracing (GOOD that you treated the patient when you did, which probably helped avert a large MI). Ken Grauer, MD

  3. Hey Steve,
    Any explanation for why the Wellen's T's became upright, yet these did not represent "re-occlusion" T's?

    1. Sam,
      T-waves can invert from active ischemia that is not infarction. When the ischemia resolves, if there is zero or very little actual infarction (and this is pretty well measured by troponins), then it can resolve. In such a case it is true normalization, not pseudonormalization.
      Very tricky, but it happens.
      I hope that was understandable.


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