a b s t r a c t

Negative T waves in electrocardiography have been widely studied. We presents a case of Wellens’ syndrome which is a pattern of global inverted T waves with QT prolongation on ECG due to transient proximal LAD occlu- sion and pointed out other differential diagnosis.

Keywords:

Wellens’ syndrome Negative T waves

After an argument with his wife, a 46-year-old male experienced paroxysmal Chest tightness and chest pain described as being like needle pricks around his left upper arm, accompanied by sweating. These symp- toms usually occurred at midnight for about 1 min, repeating hourly. After experiencing these frequently reoccurring symptoms for one week, he came to our clinic. The patient was a heavy smoker with a 20-year his- tory of alcohol consumption. He had no past history of diabetes, hyperten- sion, hyperlipidaemia nor any family history of coronary artery disease (CAD). Physical examination revealed a heart rate of 75 bpm; blood pres- sure of 125/90 mm Hg; and no lung, heart, or abdominal abnormalities.

Admission Electrocardiography (Fig. 1) showed symmetrical- ly negative T waves (NTW) in lead I, avL, and V_2-5, and biphasic T waves in leads II and V₁, and an extreme QT prolongation (QTc, 600 ms).

His troponin I level was 0.24 ng/mL (normal range, 0.0-0.1 ng/mL). The N-terminal of the prohormone brain natriuretic peptide was detected at a concentration of 405 pg/mL (normal range, 0.0-100 pg/mL).

According to patient’s history of chest pain, minimal TnI elevation, and biphasic or negative T waves in limb and precordial leads fit the criteria for Wellens’ syndrome [1]. Ischemic T waves generally point away from the area of ischemia. The ischemic region attributable to the proximal left anterior descending coronary artery lesion in- volves the left ventricle. Thus, the ischemic precordial NTW shows a rightward axis in the frontal plane and is characterized by TWI in leads I and aVL. Right ventricular apical pacing and Left bundle branch block, the most common situations leading to cardiac memory, produce positive QRS vectors in these leads, producing positive T waves upon

* Corresponding author at: 15 Yuquan Road, Beijing 100049, People’s Republic of China.

E-mail address: [email protected] (Y.-T. Zhao).

¹ Yun-Tao Zhao and Yen Shu Huang contributed equally to this work as first coauthors and also contributed to conception, design and draft of the manuscript. Lei, Wang contrib- uted to design. Yun-Tao, Zhao contributed to and approved the manuscript be submitted.

(C) 2016

normal conduction resumption. Moreover, precordial NTW are deeper than inferior NTW [2].

In differential diagnosis, acute pulmonary embolism commonly pro- duces NTW in leads III, V₁, and V₂. Lead III faces the inferior region, and leads V₁ and V₂ face the anterior region of the right ventricle [3]. In Takotsubo cardiomyopathy, NTW are more broadly distributed around lead -aVR in the limb and precordial leads, except V₁. The wall motion abnormalities in Takotsubo cardiomyopathy centre around the left ven- tricle apical region faced by lead -aVR, less frequently extending to re- gions faced by lead V₁ [4,5].

Clinical Course

Wellens’ syndrome is a pattern of inverted T waves on ECG due to transient proximal LAD occlusion. The patient underwent percutaneous coronary angiography, revealing 90% LAD occlusion (Fig. 2). Failure to recognize this pattern of Abnormal ECG changes could lead to develop- ment of anterior wall infarction and death.

Funding Sources

There were no sources of funding for this work.

Conflicts of Interest

None.

Acknowledgements

None.

References

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   http://dx.doi.org/10.1016/j.ajem.2016.11.001

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   Fig. 1. Admission ECG.

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   Fig. 2. (A) coronary angiogram showing 90% stenosis of the left anterior descending coronary artery. (B) Coronary angiogram after LAD stenting, showing TIMI3 flow.