johnston: the artful arrangment of words [smaccgold creative workshop]
TRANSCRIPT
WELLEN’S SYNDROME
Wellen’s Syndrome consists of two ECG patterns, one of which is isoelectric or minimally elevated (i.e.
less than 1mm) ST segments with a straight or convex morphology that leads into a negative (inverted)
T wave, usually commencing at an angle of between 60° and 90°, and secondly biphasic T waves. This
syndrome, because of these changes and because the main culprit is a critical proximal LAD stenosis is
not infrequently known as the LAD coronary T wave syndrome. This syndrome has only recently been
described. The first case series was by Wellens in 1982. He published his series in the American Heart
Journal. This ECG pattern is seen when the patients are pain-free. In fact, when the patient is
experiencing symptoms of angina, the ST segment – T wave abnormalities frequently normalize, or may
even develop into a pattern of ST segment elevation, plus there is, additionally, a significant number
who will have no cardiac biomarker rise, despite the severity of the LAD occlusion and the degree of
pain. Interestingly, there is an extensively long list of differential diagnoses, many of which are
constantly and repeatedly overlooked, leading to terrible outcomes in the Emergency Department if not
picked up as early as possible. These include past myocardial ischaemia, left ventricular hypertrophy,
pulmonary embolism, digoxin effect, acute intracerebral events and pericarditis. The most important
thing to know about Wellen’s Syndrome is that it is considered a pre-infarction lesion and it has a high
risk of progressing onto full anterior wall infarction within 2 to 3 weeks. The management, once
recognized, is to establish aggressive treatment strategies for coronary ischaemia. Because there is
little collateral circulation to the anterior myocardial wall, an exercise stress test should not be ordered.
The patient should be referred immediately to a cardiologist and definitive coronary imaging (an
angiogram) needs to be undertaken. Education should be also be undertaken so that this condition is
promptly recognized and patients’ lives can be saved.
In summary, you want to avoid missing this syndrome like the plague.
THE WHATEVER [CONTENT]
• Content – if you have a passion for it, so will your readers
• Simplify your point. And when you think you’ve simplified it as much as you can, simplify it further.
WELLEN’S SYNDROME
Wellen’s Syndrome consists of two ECG patterns, one of which is isoelectric or minimally elevated (i.e. less than 1mm) ST segments with a straight or convex morphology that leads into a negative (inverted) T wave, usually commencing at an angle of between 60° and 90°, and secondly biphasic T waves.
Many years later, as he faced the firing squad, Colonel
Aureliano Buendía was to remember that distant afternoon
when his father took him to discover ice.
It was love at first sight. The first time Yossarian saw the
chaplain, he fell madly in love with him.
The man in black fled across the desert, and the gunslinger
followed.
“
”
“”
“”
BEWARE WELLENS’ SYNDROME;
THE WIDOWMAKER
There are but a few ECG patterns, which, if
missed, may result in the owner’s sudden
and unexpected death. Wellens’ Syndrome
is perhaps the most feared of these, as its
ECG features can be subtle, and the usual
diagnostic criteria for an acute coronary
syndrome do not apply.
GIVE YOUR SENTENCES POWER
This syndrome, because of these changes
and because the main culprit is a critical
proximal LAD stenosis is not infrequently
known as the LAD coronary T wave
syndrome.
The diagnostic ECG changes are found in
the mid precordial leads – V2-V3 - and
comprise either deep symmetrical T wave
inversion, or biphasic T waves.
THE LILT OF RHYTHMThis syndrome has only recently been described.
The first case series was by Wellens in 1982. He
published his series in the American Heart Journal.
This ECG pattern is seen when the patients are
pain-free. In fact, when the patient is experiencing
symptoms of angina, the ST segment – T wave
abnormalities frequently normalize, or may even
develop into a pattern of ST segment elevation,
plus there is, additionally, a significant number who
will have no cardiac biomarker rise, despite the
severity of the LAD occlusion and the degree of
pain.
There is a lovely road that runs from Ixopo to the hills. These hills are grass-covered and rolling, and they are lovely beyond any singing of it.
There was music from my neighbor’s house through the summer nights. In his blue gardens men and girls came and went like moths among the whisperings and the champagne and the stars.
Professor Hein Wellens described this syndrome
relatively recently, in 1982, with a case series of
similar presentations. In his paper (American Heart
Journal) the consistent ECG pattern and clinical
features were strongly correlated with a critical
proximal LAD stenosis, and the patients had a high
rate of progression on to anterior wall myocardial
infarction if not treated (thus the alternate name, LAD
coronary T wave syndrome). Since then the condition
has become well recognized, and has been further
clarified. The ECG changes can be dynamic. During
bouts of pain, the ECG T wave changes may
paradoxically normalize, or even progress to ST
elevation, further complicating the diagnosis
CONCISION
Interestingly, there is an extensively long
list of differential diagnoses, many of
which are constantly and repeatedly
overlooked, leading to terrible outcomes
in the Emergency Department if not
picked up as early as possible.
The differential diagnosis list for
the ECG findings of precordial T
wave changes is broad, and
includes past myocardial
ischaemia, left ventricular
hypertrophy, pulmonary
embolism, digoxin effect, acute
intracerebral events and
pericarditis.
SCENEThese include past myocardial ischaemia,
left ventricular hypertrophy, pulmonary
embolism, digoxin effect, acute intracerebral
events and pericarditis. The most important
thing to know about Wellen’s Syndrome is
that it is considered a pre-infarction lesion
and it has a high risk of progressing onto full
anterior wall infarction within 2 to 3 weeks.
THE PERIL OF THE PASSIVE VOICE
Because there is little collateral circulation to
the anterior myocardial wall, an exercise
stress test should not be ordered. The
patient should be referred immediately to a
cardiologist and definitive coronary imaging
(an angiogram) needs to be undertaken.
Education should also be undertaken so that
this condition can be promptly recognized
and patients’ lives can be saved.
Once the diagnosis is suspected, the
clinician should make a hasty referral to the
Cardiology team. Exercise Stress Testing is
contraindicated, as these patients have little
collateral circulation to the anterior
myocardial wall, and catastrophic collapse
may ensue. Instead, prompt and aggressive
treatment for an acute coronary syndrome
should be instituted, and definitive imaging
and revascularization sought.
THUS, like a newly discovered and
deadly animal species from the
Amazon, the Wellenoid pattern has
only recently crept into our critical care
consciousness. It is dangerous, and
well camouflaged, and it takes a skilled
and knowledgeable practitioner to spot
it, in order to avoid its precipitous death
strike.