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Intermittent Chest Pain in a 46-Year-Old Patient

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 46-year-old man with no significant medical history presented to the emergency department (ED) 6 hours after a 20-minute episode of chest pain and diaphoresis that occurred at rest and resolved spontaneously. Two days earlier, he reported a similar 20-minute episode of chest pain and diaphoresis. The patient currently smoked 30 cigarettes per day and had a 20 pack-year history of smoking. He was taking no daily medications and had no family history of cardiovascular disease. On admission to the ED, the patient was asymptomatic. Blood pressure was 102/74 mm Hg, heart rate was 84/min, and oxygen saturation was 100% on room air. His physical examination results were unremarkable. Laboratory testing produced the following results: troponin T, 16 ng/mL (reference, <14 ng/mL); creatine kinase (CK), 82 U/L (1.37 µkat/L) (reference, <190 U/L [<3.17 µkat/L]); CK-MB, 16 U/L (reference, <24 U/L); low-density lipoprotein (LDL) cholesterol, 106 mg/dL (2.75 mmol/L) (reference, <130 mg/dL [<3.37 mmol/L]); and high-density lipoprotein (HDL) cholesterol, 38 mg/dL (0.98 mmol/L) (reference, >35 mg/dL [>0.91 mmol/L]). His initial electrocardiogram (ECG) is shown in Figure 1.

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Wellens syndrome type A

C. Perform coronary angiography

The key to the correct diagnosis is recognition that the biphasic T wave in leads V2 and V3 on ECG in a patient with recent chest pain may suggest impending coronary artery occlusion. Discharge home (choice A) is not recommended, and a dobutamine stress echocardiogram (choice C) is contraindicated in patients with ongoing unstable angina. Choice D is incorrect because, based on these ECG findings, coronary angiography should be performed regardless of blood troponin levels.

Wellens syndrome represents specific T-wave patterns on ECG obtained during a chest pain–free interval that may herald development of an acute myocardial infarction.1 Wellens syndrome is found in 5.7% of patients with acute coronary syndrome (ACS)2 and 8.8% of patients with non–ST-elevation myocardial infarction (NSTEMI) who undergo coronary angiography.3 Among patients with NSTEMI, those with Wellens syndrome are less likely to have a history of coronary heart disease or previous percutaneous coronary intervention (PCI) than individuals without Wellens.2

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Article Information

Corresponding Author: Christian Oeing MD, Department of Internal Medicine and Cardiology, Charité-University Medicine Berlin, Campus Virchow Klinikum, Berlin, Germany (christian.oeing@charite.de).

Published Online: October 31, 2022. doi:10.1001/jama.2022.19443

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
1.
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(4 pt 2):730-736. doi:10.1016/0002-8703(82)90480-XPubMedGoogle ScholarCrossref
2.
Zhou  L , Gong  X , Dong  T ,  et al.  Wellens’ syndrome: incidence, characteristics, and long-term clinical outcomes.   BMC Cardiovasc Disord. 2022;22(1):1-8. doi:10.1186/s12872-022-02560-6PubMedGoogle ScholarCrossref
3.
Kobayashi  A , Misumida  N , Aoi  S , Kanei  Y .  Prevalence and clinical implication of Wellens’ sign in patients with non-ST-segment elevation myocardial infarction.   Cardiol Res. 2019;10(3):135-141. doi:10.14740/cr856PubMedGoogle ScholarCrossref
4.
Rhinehardt  J , Brady  WJ , Perron  AD , Mattu  A .  Electrocardiographic manifestations of Wellens’ syndrome.   Am J Emerg Med. 2002;20(7):638-643. PubMedGoogle ScholarCrossref
5.
Arshad  S , Ferrick  NJ , Monrad  ES ,  et al.  Prevalence and association of the Wellens’ sign with coronary artery disease in an ethnically diverse urban population.   J Electrocardiol. 2020;62:211-215. PubMedGoogle ScholarCrossref
6.
Avram  A , Chioncel  V , Iancu  A ,  et al.  Wellens sign: monography and single center experience.   Maedica (Bucur). 2021;16(2):216-222.PubMedGoogle Scholar
7.
Migliore  F , Zorzi  A , Marra  MP ,  et al.  Myocardial edema underlies dynamic T-wave inversion (Wellens’ ECG pattern) in patients with reversible left ventricular dysfunction.   Heart Rhythm. 2011;8(10):1629-1634. doi:10.1016/j.hrthm.2011.04.035PubMedGoogle ScholarCrossref
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