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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Corresponding Author: Christian Oeing MD, Department of Internal Medicine and Cardiology, Charité-University Medicine Berlin, Campus Virchow Klinikum, Berlin, Germany (firstname.lastname@example.org).
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.
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