Takotsubo Cardiomyopathy Presenting as Wellens' Syndrome

Critical Stenosis in Left Anterior Descending Artery: Beware of T- Wave Inversions

Wellens’ syndrome (WS) is a pattern on an electrocardiogram (ECG) characterized by biphasic T waves or deeply inverted T waves in leads V2-V3 with a recent clinical history of angina. Wellens’ pattern on the ECG is particular for critical left anterior descending artery (LAD) stenosis. Wellens’ sign and WS have been used interchangeably in the literature. However, the typical patterns of ECG changes noted are mostly represented by Wellens’ sign. These ECG changes have been crucial in identifying this subset of patients with severe LAD disease.

Entire process of electrocardiogram recording of Wellens syndrome: A case report

BACKGROUND

Wellens syndrome is an electrocardiogram (ECG) pattern seen in high-risk patients with unstable angina pectoris. It is characterized by inverted or biphasic T-waves that change into positive or pseudo-normalized waves at precordial leads when the patient experiences an angina attack; however, the mechanism for this condition remains unclear.

CASE SUMMARY

A 47-year-old male patient experienced repeated, unprovoked episodes of chest pain for > 20 d, with worsening during the previous day. On the day of admission, he experienced episodes of paroxysmal chest pain lasting more than 30 min, in addition to radiating pain to the left arm and exertional dyspnea. The patient presented to the emergency department with no chest pain or other discomfort at that time. ECG at presentation showed sinus tachycardia and T-wave changes, which were identified as Wellens syndrome when combined with previous ECG findings. ECGs and myocardial enzymology examinations were normal when angina was present, but the ECG showed inverted or biphasic T-waves when angina was absent. After percutaneous coronary intervention, the ECGs demonstrated inverted or biphasic T-waves in the anterior precordial leads on days 0, 1, and 2, but normal T-waves on day 3. The ECGs showed no subsequent ischemic ST-T-wave changes.

CONCLUSION

The Wellens syndrome pseudo-normalized T-waves likely reflect development of unstable angina pectoris into the hyperacute phase of ST-segment elevation myocardial infarction.

Wellens’ Syndrome from COVID-19 Infection Assessed by Enhanced Transthoracic Coronary Echo Doppler: A Case Report

Wellens’ syndrome (WS) is a preinfarction state caused by a sub-occlusion of the proximal left anterior descending coronary artery (LAD). In this case report, for the first time, we describe how this syndrome can be caused by COVID-19 infection and, most importantly, that it can be assessed bedside by enhanced transthoracic coronary echo Doppler (E-Doppler TTE). This seasoned technique allows blood flow Doppler to be recorded in the coronaries and at the stenosis site but has never been tested in an acute setting. Two weeks after clinical recovery from bronchitis allegedly caused by COVID-19 infection on the basis of epidemiologic criteria (no swab performed during the acute phase but only during recovery, at which time it was negative), our patient developed typical angina for the first time, mainly during effort but also at rest. He was admitted to our tertiary center, where pharyngeal swabs tested positive for COVID-19. A typical EKG finding supporting WS prompted an assessment of the left main coronary artery (LMCA) and the whole LAD blood flow velocity by E-Doppler TTE. Localized high velocity (transtenotic velocity) (100 cm/s) was recorded in the proximal LAD, with the reference velocity being 20 cm/s. This indicated severe stenosis with 90% area narrowing according to the continuity equation, as confirmed by coronary angiography. During follow-up after successful stenting, E-Doppler TTE showed a decrease in the transtenotic acceleration, confirming stent patency and a normal coronary flow reserve (3.2) and illustrating a normal microcirculatory function. Conclusion: COVID infection can trigger a coronary syndrome like WS. E-Doppler TTE, an ionizing radiation-free method, allows safe and rapid bedside management of the syndrome. This new strategy can be pivotal in distinguishing true WS from pseudo-WS. In cases of pseudo-WS, coronary angiography can be avoided. If E-Doppler TTE confirms the stenosis and PCI (percutaneous coronary intervention) is performed, the same method can allow assessment over time of the precise residual stenosis after stenting and verify the microvasculature status by evaluating coronary flow reserve.

Myocardial bridging-an unusual cause of Wellens syndrome: A case report

RATIONALE

Coronary chest pain is usually ischemic in etiology and has various electrocardiographic presentations. Lately, it has been recognized that myocardial bridging (MB) with severe externally mechanical compression of an epicardial coronary artery during systole may result in myocardial ischemia. Such a phenomenon can be associated with chronic angina pectoris, acute coronary syndromes (ACS), coronary spasm, ventricular septal rupture, arrhythmias, exercise-induced atrioventricular conduction blocks, transient ventricular dysfunction, and sudden death.

PATIENT CONCERNS

We report the case of a 58-year-old woman presenting with recurrent episodes of constrictive chest pain during exercise within the last 2 weeks. Except for obesity, general and cardiovascular clinical examination on admission were normal.

DIAGNOSES

The resting 12 lead electrocardiogram (ECG) revealed changes typically for Wellens syndrome. High-sensitive cardiac troponin I was normal. We established the diagnosis of low-risk non-ST-segment elevation acute coronary syndrome with a Global Registry of Acute Coronary Events risk score of 92 points.

INTERVENTIONS

The patient underwent coronary angiography, who showed subocclusive dynamic obstruction of the left anterior descending artery due to MB.

OUTCOMES

The patient was managed conservatively. Her hospital course was uneventful and she was discharged on pharmacological therapy (clopidogrel, bisoprolol, amlodipine, atorvastatin, and metformin) with well-controlled symptoms on followup.

LESSONS

MB is an unusual cause of myocardial ischemia. Wellens syndrome is an unusual presentation of ACS. We present herein a rare case of Wellens syndrome caused by MB. This case highlights the importance of subtle and frequently overseen ECG findings when assessing patients with chest pain and second, the importance of considering nonatherosclerotic causes for ACS.