J. Hartman, B.J.H. van Kempen, P.R. Tuinman Department of Intensive Care Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
J. Hartman – email@example.com. ORCID ID: 0000-0003-2538-3856
Electrocardiographic changes typical for Wellens’ syndrome
A 77-year-old male was admitted with COVID-19 requiring intubation, prone positioning and treatment for bilateral segmental pulmonary embolism. Medical history consisted of type 2 diabetes and stable chronic lymphocytic leukaemia. Two weeks after intubation, he developed electrocardiographic changes with deeply inverted T waves in leads V2 to V4 (figure 1). Electrolytes were normal. Cardiac biomarkers were significantly elevated. The day after, a transthoracic echocardiography showed moderate left ventricular dysfunction with anterior wall akinesia and normal right ventricular function. The patient was treated conservatively with a beta blocker and clopidogrel on top of unfractionated heparin. Four days later he went into cardiac arrest due to ventricular fibrillation for which cardiopulmonary resuscitation and defibrillation were performed with return of spontaneous circulation. Coronary angiogram demonstrated significant stenosis of the distal left main coronary artery and proximal left anterior descending artery (LAD), for which a bifurcation stenting procedure was performed successfully. Triple anticoagulation therapy was started. Despite a negative fluid balance with loop diuretics in the days after coronary intervention, progression of hypoxaemia persisted and the patient died after the transition of the treatment goals from cure to comfort.
Wellens’ syndrome, also known as LAD coronary syndrome, is a clinical syndrome specific for critical stenosis of the LAD. It was first described by De Zwaan et al. in 1982 in patients with unstable angina, of which 75% developed anterior wall myocardial infarction weeks after admission. Electrocardiographic changes can beclassified in two types. Type A is characterised by biphasic terminal negative T waves in leads V2 and V3 and occurs in approximately 25% of cases (figure 2). Type B is characterised by deeply inverted T waves in leads V2 and V3 and occurs in approximately 75% of cases.
In both types the T wave abnormalities can extend from V1 to V6 and the ST segment is isoelectric or minimally elevated (<1 mm). Precordial Q waves are absent and R wave progression is normal. A history of chest pain is necessary for diagnosis but can be difficult to obtain in ICU patients. Cardiac biomarkers should be normal or slightly elevated, but in ICU patients multiple factors can contribute to a more significant elevation. The T wave abnormalities could be explained by transient complete occlusion and reperfusion, mimicking the changes seen with reperfusion after coronary intervention. The differential diagnosis consists of pulmonary embolism, left ventricular hypertrophy, Brugada syndrome, hypokalaemia and raised intracranial pressure.
The patient in our case had an increased risk for coronary atherosclerosis due to age and diabetes. COVID-19 increases the risk of arterial thrombosis and causes an unfavourable balance between myocardial oxygen consumption and delivery. These factors probably contributed to transient myocardial ischaemia of the anterior wall and manifestation of the electrocardiographic abnormalities. Recognition of these specific electrocardiographic findings is important as timely diagnosis should trigger early invasive angiographic assessment.
All authors declare no conflict of interest. No funding or financial support was received. Written informed consent was obtained from the patient’s next of kin for the publication of this case report and the electrocardiogram.
- de Zwaan C, Bär 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