What is Wellens Syndrome?
Wellens syndrome is a condition that appears as specific irregularities on an electrocardiogram (ECG), a test that monitors the heart’s activity. This includes unusually deep upturned or two-phase wave patterns in certain readings (V2-V3). This syndrome points towards a critical narrowing of a key heart artery known as the left anterior descending (LAD) artery. It’s also sometimes referred to as anterior, descending, T-wave syndrome.
People with Wellens syndrome often come to the emergency department without any pain, and their heart-related enzymes (substances in the body that indicate heart function) are usually normal or only slightly above normal. However, it’s crucial to identify this ECG pattern as these individuals are at a high risk of experiencing a severe heart attack affecting the front wall of the heart.
An interesting fact is that when this syndrome was first discovered in the early 1980s by Drs. De Zwaan, Wellens, and their team, they observed that 75% of patients with these ECG signs experienced a severe, front wall heart attack within weeks if they only received drug treatment. Therefore, the best course of action often involves a procedure called cardiac catheterization with percutaneous coronary intervention (PCI). Here, a long, thin tube is inserted into an artery or vein and guided to the heart. The heart specialist can then perform diagnostic tests and treatments on the heart, notably opening up the blocked LAD artery to prevent an impending heart attack.
What Causes Wellens Syndrome?
Wellens syndrome is caused by conditions similar to those that cause heart disease. These include:
* Buildup of fats, cholesterol and other substances in and on the artery walls, also known as atherosclerotic plaque.
* Sudden tightening or narrowing of the arteries that supply blood to the heart, a condition known as coronary artery vasospasm.
* Lack of enough oxygen in your body, a condition called hypoxia.
* An increase in the heart’s workload due to conditions like high blood pressure.
Certain factors can increase your risk of developing Wellens syndrome. These include:
* Diabetes.
* Having a family history of heart disease at a young age.
* High blood pressure.
* Getting older.
* High cholesterol levels.
* High levels of fats in your blood, also known as hyperlipidemia.
* Metabolic syndrome, a cluster of conditions including high blood pressure, high blood sugar, excess body fat around the waist, and abnormal cholesterol or triglyceride levels.
* Stress at work.
* Smoking.
Risk Factors and Frequency for Wellens Syndrome
Wellens syndrome is a condition that is essentially a pre-heart attack situation, caused by artery disease. The factors that put people at risk for Wellens syndrome are the same as those that lead to artery disease, such as high cholesterol, high blood pressure, diabetes, lack of physical activity, obesity, family history, and smoking. People with Wellens syndrome typically show an ECG pattern that is common in people with unstable angina, which is chest pain that occurs even at rest.
- Wellens syndrome is a pre-heart attack condition related to artery disease.
- High cholesterol, high blood pressure, diabetes, lack of physical activity, obesity, family history, and smoking are all risk factors for Wellens syndrome.
- An ECG pattern typical of Wellens syndrome can be observed in people with unstable angina.
- Studies by Dr. Wellens and his team found this ECG pattern in 14% to 18% of patients admitted for unstable angina.
Signs and Symptoms of Wellens Syndrome
Wellens syndrome is a cardiac condition, often associated with symptoms similar to acute coronary syndrome such as chest discomfort. These symptoms typically include chest tightness or pressure that is most commonly triggered by physical activities and relieved by rest. This chest pain can often spread to the neck, jaw, or shoulder. When patients arrive at the emergency department, they are usually not in pain. However, specific patterns may still be apparent in their electrocardiogram (ECG) results. Even though patients may appear comfortable and show no significant signs during a physical exam, they may show mild distress and sweating, similar to symptoms observed in patients suffering from a heart attack.
Testing for Wellens Syndrome
If a doctor suspects that a patient might be suffering from Wellens syndrome, a condition that affects the heart, there are certain criteria they look for. The items that they check are largely based on an electrocardiogram (ECG), which is a test that measures the electrical activity of the heart.
On an ECG, they will be looking for specific patterns, such as deeply inverted or ‘upside-down’ T waves in certain sections. These are typically spotted in areas labelled V2 and V3, but may also appear in V1, V4, V5, and V6. Instead of inverted T waves, these could also be biphasic (having two phases). Here, the waves start positively but end negatively.
Other ECG signs include an isoelectric or minimally elevated ST segment, which is, in simple terms, a flat or slightly raised line on the ECG reading. This would indicate that there are no signs of severe damage to the heart. Another criteria is the preservation of something called ‘precordial R-wave progression’ and the absence of precordial Q waves. These two signs also suggest that there hasn’t been any significant past damage to the heart’s anterior wall, which is the front of the heart.
Other indicators include a recent history of angina, which is a chest pain that happens because your heart isn’t getting enough oxygen-rich blood. Importantly, it is essential for these ECG patterns to be present even when the patient is not experiencing pain. Other elements the doctor will be checking for include normal or only minimally elevated cardiac markers, which are substances in the blood that could indicate heart damage or disease.
There are two main types of T wave patterns in Wellens syndrome. About 25% of patients with Wellens syndrome have type-A waves, which are biphasic. Type-B waves, which are deeply and symmetrically inverted, are present in around 75% of cases. It’s thought that type-A waves can evolve into type-B waves. These abnormal wave patterns can stay the same for a lengthy period of time, from hours to weeks, even when the patient doesn’t have chest pain.
Wellens syndrome doesn’t always show up immediately. It can develop slowly, over days or even weeks. Often, the telltale ECG patterns emerges when the patient isn’t having chest pain. When they do experience chest pain, the ST segment and T-wave patterns can seem to normalize, or even show elevations.
It’s important to be aware that one measure used to assess heart health, cardiac biomarkers like troponin, may not provide accurate information in patients with Wellens syndrome. Often, these will be within normal limits. In a study, only 12% of patients displaying the ECG pattern of Wellens syndrome showed elevated cardiac markers, and those that were elevated were only slightly above the upper limit of normal.
Treatment Options for Wellens Syndrome
Wellens syndrome is a potentially serious heart condition. If a doctor suspects that you might have Wellens syndrome, they will usually arrange for you to see a heart specialist known as a cardiologist. In more complex cases, you might also see a sub-specialist called an interventional cardiologist, who can perform specific procedures on your heart. The primary treatment for Wellens syndrome is a procedure called cardiac catheterization with PCI.
In the lead-up to this procedure, the treatment for Wellens syndrome is similar to that for a heart attack. This treatment could include medications that break up clots, like aspirin and heparin, and other heart medications like nitrates and beta blockers. These medications are only used if your blood pressure is normal. It’s important to understand that Wellens syndrome doesn’t respond particularly well to medication alone – definitive treatment efforts usually involve procedures performed by the cardiologist.
Patients with Wellens syndrome who are not experiencing symptoms and are otherwise stable can be admitted to a regular hospital ward where they can be closely monitored. If you do have symptoms, you will most likely be admitted to the Intensive Care Unit (ICU), where you can be closely supervised. You would likely also see the interventional cardiologist relatively quickly, to have the cardiac catheterization.
One key factor in Wellens syndrome is that there can be significant narrowing of a crucial heart artery, known as the LAD coronary artery. For this reason, stress tests, which put the heart under strain, should be avoided. These tests could bring on a heart attack or sudden death. Once a cardiologist performs a detailed heart scan called a coronary angiography, they will plan a strategy to improve the blood flow in the LAD coronary artery.
What else can Wellens Syndrome be?
When looking for the cause of changes in your EKG, specifically a pattern called “anterior T-wave inversion”, doctors have to think about a handful of possible causes:
- Central nervous system injury
- Left ventricular hypertrophy (enlarged heart)
- Right bundle branch block (a delay in the way your heart’s electricity travels)
- Hypertrophic cardiomyopathy (a type of heart disease that can cause a sudden cardiac arrest)
- Pulmonary embolism (blood clot in your lungs)
These patterns can be separated from each other based on extra details from the EKG that aren’t covered in this discussion.
When a ‘Wellens pattern’ appears, it’s usually a sign of a buildup in the heart artery. However, similar patterns can appear with the use of drugs like cocaine or marijuana, where they can cause spasms in the arteries. When the drugs are no longer in the body, the EKG tends to return to normal. Knowing this can be important, particularly when dealing with a young patient with no obvious reasons for a heart attack risk, since some medicines can actually make things worse if the cause is drug-related.
Sometimes ‘pseudo-Wellens syndrome’ can also show up because of a rare condition where the heart artery goes under a bridge of heart muscle, which results in a buildup. The ‘Wellens pattern’ can also be seen in a condition called ‘Takotsubo cardiomyopathy’, which is believed to be a result of swelling in the heart muscle.
What to expect with Wellens Syndrome
Wellens syndrome, as previously mentioned, is a medical condition resulting from severe narrowing of the left anterior descending coronary artery, which is an artery that carries blood to the heart. This condition is detectable through specific changes that occur in an EKG, a test that measures the electrical activity of your heartbeat.
Essentially, Wellens syndrome is a warning sign, indicating that you are in a ‘pre-heart attack’ state. If it isn’t recognized and treated in time, the condition can develop into a severe heart attack involving the front wall of the heart. This can lead to significant health complications and even death.
Hence, it’s crucial that healthcare providers correctly identify the early signs of Wellens syndrome to potentially prevent these serious outcomes.
