Wellens' syndrome

2 types of Wellens' waves

• • Type 1 - Deeply symmetric TWI

  • Type 2 - Biphasic T waves with terminal TWI. Goes up first, then down (often misdiagnosed as “normal” or “non-specific T-wave abnormality”).Pattern of T-wave abnormality in mid precordial leads (V₂-V₃, +/-V₄)

• Highly specific for critical obstruction of the proximal LAD

• High risk for extensive anterior wall MI and death

• ST changes are often absent and patient can be chest pain free!

• Cardiac biomarkers often initially normal

• Best to diagnose in absence of high voltage, as there are normal variants, see "pseudo-wellens"

• When in doubt get serial ECG’s, some will evolve into STEMI!