Wellens' Syndrome || # aetcm || #emergencymedicine ||

Added: 2026-06-03

[00:00:06]Welcome to ADC, the emergency medicine channel.

[00:00:09]In this video, we are going to discuss one of the most and important potentially life-saving ECG patterns in emergency medicine, Wellens syndrome.

[00:00:18]This is an ECG finding that every healthcare professional must recognize because the patient may look stable, may be pain-free, and may even have normal cardiac enzymes. Yet, we are only hours or days away from a devastating anterior wall myocardial infarction.

[00:00:36]So, let's begin. Imagine a patient arrives in the emergency department with a history of severe chest pain.

[00:00:44]By the time you see the patient, the pain has completely resolved. Vital signs are stable, troponin levels are normal or only minimally elevated.

[00:00:55]The patient appears comfortable. Many clinicians may feel reassured. But then, you look at the ECG.

[00:01:02]And the ECG, it is warning you about a critical stenosis of the proximal left anterior descending artery or LAD, often called the widowmaker artery.

[00:01:15]This warning sign is known as Wellens syndrome.

[00:01:19]Wellens syndrome is characterized by the characteristic T wave abnormalities in the anterior chest leads, especially V2 and V3, in a patient with a recent history of anginal chest pain that has now resolved.

[00:01:34]There are two classic ECG patterns. Type A Wellens pattern shows biphasic T waves in leads V2 and V3. The T wave initially goes upward and downward. This pattern accounts for approximately 25% of cases.

[00:01:50]The second and more common pattern is type B Wellens pattern. Here, the T waves are deeply and symmetrically inverted in the anterior leads. This accounts for 75% of the cases.

[00:02:05]Also, note that the T wave changes can evolve over the time from type A to type B pattern.

[00:02:12]Now comes the most important concept.

[00:02:14]The ECG pattern is usually seen when the patient is pain free.

[00:02:19]During active chest pain, these T T wave changes may disappear and appear deceptively normal.

[00:02:27]This phenomenon is called pseudo normalization.

[00:02:30]In reality, pseudo normalization often indicates reocclusion of the LAD artery and worsening ischemia.

[00:02:38]So, remember a normal looking ECG during recurrent chest pain does not always mean improvement. Sometimes, it means the artery has occluded again.

[00:02:49]So, why does this happen?

[00:02:52]The current understanding is that the LAD artery becomes temporarily occluded producing myocardial ischemia.

[00:03:00]Spontaneous reperfusion then occurs either naturally or after medication such as aspirin.

[00:03:07]As blood flow as blood flow returns, the chest pain improves and the characteristic Wellens T wave pattern appears on the ECG.

[00:03:16]However, the artery remains critically narrowed and can close again at any moment.

[00:03:23]That is why Wellens syndrome is often described as a pre-infarction syndrome.

[00:03:29]Without definitive treatment, many patients progress to a large large anterior wall myocardial infarction within days to weeks. So, what are the diagnostic clues?

[00:03:40]A recent history of chest pain, the patient currently being pain free, biphasic or deeply inverted T waves in to V3, minimal or no ST segment elevation, no pathological Q waves, preserved R wave progression, and normal or only slightly elevated cardiac biomarkers.

[00:04:03]Now, for the most important management here, never stress test a patient with suspected Wellens syndrome.

[00:04:11]Exercise stress testing may be may precipitate complete LAD occlusion resulting in myocardial infarction, ventricular arrhythmias, cardiac arrest, or death.

[00:04:23]Instead, these patients require urgent cardiology evaluation and early coronary angiography with revascularization whenever indicated.

[00:04:33]So, never ignore biphasic or deeply inverted T waves in V2 and V3 in a patient with recent chest pain. So, recognize it and act on it because identifying Wellens syndrome today may prevent a catastrophic myocardial infarction tomorrow.

[00:04:50]Thank you for watching.