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Wellens Syndrome with a Pacemaker Rhythm
The Journal of Emergency Medicine, Vol. 44, No. 1, pp. e123–e124, 2013 Copyright Ó 2013 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2012.02.083
Visual Diagnosis in Emergency Medicine
WELLENS SYNDROME WITH A PACEMAKER RHYTHM Cenker Eken, MD,* Emre Altekin, MD,† and Mustafa Serkan Karakas, MD† *Department of Emergency Medicine and †Department of Cardiology, Akdeniz University Faculty of Medicine, Antalya, Turkey Reprint Address: Cenker Eken, MD, Department of Emergency Medicine, Akdeniz University Faculty of Medicine, Antalya 07059, Turkey
CASE REPORT
to QRS axis, in leads V4 and V5, and minimal ST elevations with concordance inverted T waves to QRS axis in leads V2 and V3 with a pace rhythm (Figure 1). The most recent ECG available for comparison, which was obtained approximately 1 month prior, showed a paced rhythm and concordance inverted T waves in leads V5 and V6, and discordance inverted T waves in leads I and aVL (Figure 2). The patient was admitted to Cardiology for cardiac catheterization, which showed a 98% occlusion of the proximal left anterior descendent coronary artery. A stent was placed successfully.
An 80-year-old woman presented to the Emergency Department at 11:00 a.m. with squeezing chest pain in the left chest radiating to the neck. The pain started at 2:00 a.m. and lasted 30 min. She had a history of coronary artery disease and a pacemaker implantation, along with medical therapy. The physical examination was unremarkable, with normal vital signs. Cardiac enzymes troponin T and creatine kinase-MB Mass were within normal limits during the admission. An electrocardiogram (ECG) performed during the visit demonstrated deep and symmetrically inverted T waves, concordance
Figure 1. Deep and symmetrically inverted T waves in leads V4 and V5 (thick arrow) and minimal ST elevations with negative T waves in leads V2 and V3 (thin arrow) with a pace rhythm.
Figure 2. Pacemaker rhythm with negative T waves in anterolateral and high lateral leads.
RECEIVED: 2 August 2011; FINAL SUBMISSION RECEIVED: 7 October 2011; ACCEPTED: 22 February 2012 e123
e124
C. Eken et al.
Figure 3. Deeply and symmetrically inverted T waves in leads V4 and V5, and minimal ST segment elevation with negative T waves in leads V2 and V3 (Wellens syndrome in a patient without a pacemaker).
(comprising 75%) or biphasic T waves (less common) (Figure 3) (1,2). The presence of a pacemaker makes it more challenging to identify acute MI with an ECG. Sgarbossa et al. defined the ECG criteria for diagnosing MI in patients with a pacemaker (3). Concordance ST-segment elevation >1 mm, discordance ST segment elevation >5 mm, and ST depression in V1–3 > 1 mm have a specificity of 98%, 88%, and 82%, respectively, according to the Sgarbossa criteria. The present case shows that ECG findings typically noted in Wellens syndrome may be an indication of acute coronary syndrome in patients with pacemakers. REFERENCES
DISCUSSION Wellens syndrome is critical stenosis of the left anterior descendent coronary artery, with a risk of extensive anterior myocardial infarction (MI) if flow is not rapidly established. It is characterized by ST-T segment changes in precordial leads, predominantly in V1 to V4. The ST segment can be normal or minimally elevated. The major characteristic change is T-wave abnormality that is either symmetrical and deeply inverted T waves
1. de Zwaan C, Ba¨r FW, Wellens HJ. Characteristic electrocardiographic pattern indicating a critical stenosis high in left anterior descending coronary artery in patients admitted because of impending myocardial infarction. Am Heart J 1982;103:730–6. 2. de Zwaan C, Ba¨r FW, Janssen JH, et al. Angiographic and clinical characteristics of patients with unstable angina showing an ECG pattern indicating critical narrowing of the proximal LAD coronary artery. Am Heart J 1989;117:657–65. 3. Sgarbossa EB, Pinski SL, Gates KB, et al. Early electrocardiographic diagnosis of acute myocardial infarction in the presence of ventricular-paced rhythm. GUSTO-I investigators. Am J Cardiol 1996;77:423–4.
http://dx.doi.org/10.1016/j.jemermed.2012.02.083
Visual Diagnosis in Emergency Medicine
WELLENS SYNDROME WITH A PACEMAKER RHYTHM Cenker Eken, MD,* Emre Altekin, MD,† and Mustafa Serkan Karakas, MD† *Department of Emergency Medicine and †Department of Cardiology, Akdeniz University Faculty of Medicine, Antalya, Turkey Reprint Address: Cenker Eken, MD, Department of Emergency Medicine, Akdeniz University Faculty of Medicine, Antalya 07059, Turkey
CASE REPORT
to QRS axis, in leads V4 and V5, and minimal ST elevations with concordance inverted T waves to QRS axis in leads V2 and V3 with a pace rhythm (Figure 1). The most recent ECG available for comparison, which was obtained approximately 1 month prior, showed a paced rhythm and concordance inverted T waves in leads V5 and V6, and discordance inverted T waves in leads I and aVL (Figure 2). The patient was admitted to Cardiology for cardiac catheterization, which showed a 98% occlusion of the proximal left anterior descendent coronary artery. A stent was placed successfully.
An 80-year-old woman presented to the Emergency Department at 11:00 a.m. with squeezing chest pain in the left chest radiating to the neck. The pain started at 2:00 a.m. and lasted 30 min. She had a history of coronary artery disease and a pacemaker implantation, along with medical therapy. The physical examination was unremarkable, with normal vital signs. Cardiac enzymes troponin T and creatine kinase-MB Mass were within normal limits during the admission. An electrocardiogram (ECG) performed during the visit demonstrated deep and symmetrically inverted T waves, concordance
Figure 1. Deep and symmetrically inverted T waves in leads V4 and V5 (thick arrow) and minimal ST elevations with negative T waves in leads V2 and V3 (thin arrow) with a pace rhythm.
Figure 2. Pacemaker rhythm with negative T waves in anterolateral and high lateral leads.
RECEIVED: 2 August 2011; FINAL SUBMISSION RECEIVED: 7 October 2011; ACCEPTED: 22 February 2012 e123
e124
C. Eken et al.
Figure 3. Deeply and symmetrically inverted T waves in leads V4 and V5, and minimal ST segment elevation with negative T waves in leads V2 and V3 (Wellens syndrome in a patient without a pacemaker).
(comprising 75%) or biphasic T waves (less common) (Figure 3) (1,2). The presence of a pacemaker makes it more challenging to identify acute MI with an ECG. Sgarbossa et al. defined the ECG criteria for diagnosing MI in patients with a pacemaker (3). Concordance ST-segment elevation >1 mm, discordance ST segment elevation >5 mm, and ST depression in V1–3 > 1 mm have a specificity of 98%, 88%, and 82%, respectively, according to the Sgarbossa criteria. The present case shows that ECG findings typically noted in Wellens syndrome may be an indication of acute coronary syndrome in patients with pacemakers. REFERENCES
DISCUSSION Wellens syndrome is critical stenosis of the left anterior descendent coronary artery, with a risk of extensive anterior myocardial infarction (MI) if flow is not rapidly established. It is characterized by ST-T segment changes in precordial leads, predominantly in V1 to V4. The ST segment can be normal or minimally elevated. The major characteristic change is T-wave abnormality that is either symmetrical and deeply inverted T waves
1. de Zwaan C, Ba¨r FW, Wellens HJ. Characteristic electrocardiographic pattern indicating a critical stenosis high in left anterior descending coronary artery in patients admitted because of impending myocardial infarction. Am Heart J 1982;103:730–6. 2. de Zwaan C, Ba¨r FW, Janssen JH, et al. Angiographic and clinical characteristics of patients with unstable angina showing an ECG pattern indicating critical narrowing of the proximal LAD coronary artery. Am Heart J 1989;117:657–65. 3. Sgarbossa EB, Pinski SL, Gates KB, et al. Early electrocardiographic diagnosis of acute myocardial infarction in the presence of ventricular-paced rhythm. GUSTO-I investigators. Am J Cardiol 1996;77:423–4.