[Skip to Content]
[Skip to Content Landing]

Ominous Electrocardiographic Patterns in an Older Adult With Chest Pain

To identify the key insights or developments described in this article
1 Credit CME

An older adult with a history of hypertension and diabetes presented to the emergency department with paroxysmal chest pain. The chest pain had occurred 6 times during the day and was relieved by sublingual nitroglycerin. On arrival, the patient’s blood pressure and pulse rate were 160/86 mmHg and 45 beats per minute (bpm), respectively. Results of a hemogram, serum electrolyte, kidney, liver, troponin I, B-type natriuretic peptide, and D-dimer tests were all within normal limits. The chest pain resolved before the initial electrocardiogram (ECG) was performed (Figure, A). The diagnosis was unstable angina, and loading doses of aspirin, ticagrelor, and atorvastatin were prescribed. On the second day of hospitalization, the chest pain recurred. A repeat ECG was performed at the onset of chest pain (Figure, B).

Please finish quiz first before checking answer.

You answered correctly!

Read the answer below and download your certificate.

You answered incorrectly.

Read the discussion below and retake the quiz.

There are 3 ominous patterns in this patient’s ECG findings. First is Wellens syndrome, represented by biphasic or deeply negative T waves in anterior leads (V2-V4; occasionally in leads V1, V4-V6) with isoelectric or minimally elevated (1 mm) ST-segments.1 This ECG pattern has a major diagnostic and prognostic significance. Wellens syndrome is consistent with a preinfarction stage of coronary artery disease and correlates with critical stenosis (often subocclusion) of the proximal left anterior descending artery. When Wellens syndrome is recognized, urgent percutaneous coronary intervention should be performed to arrest the progression to extensive anterior-wall infarction and consequent mortality.2 The receiving physician was not aware of the risk of this ECG pattern when the patient was admitted, and the patient eventually developed acute ST-segment elevation myocardial infarction (STEMI).

Survey Complete!

Sign in to take quiz and track your certificates

Buy This Activity

JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 Credit(s)™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC

CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Corresponding Author: Xuanxuan Li, MD, Department of Cardiology, Shijiazhuang Great Wall Hospital of Integrated Traditional Chinese and Western Medicine, Shijiazhuang, Hebei 050000, China (xuanxuanlidiyi@163.com).

Published Online: January 17, 2023. doi:10.1001/jamainternmed.2022.6092

Conflict of Interest Disclosures: None reported.

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.
Kannan  L , Figueredo  VM .  Images in clinical medicine. Wellens’ syndrome.   N Engl J Med. 2015;372(1):66. doi:10.1056/NEJMicm1400946PubMedGoogle ScholarCrossref
3.
Kukla  P , Jastrzebski  M , Sacha  J , Bryniarski  L .  Lambda-like ST segment elevation in acute myocardial infarction: a new risk marker for ventricular fibrillation? three case reports.   Kardiol Pol. 2008;66(8):873-877.PubMedGoogle Scholar
4.
Testa-Fernández  A , Rios-Vazquez  R , Sieira-Rodríguez-Moret  J ,  et al.  “Giant R wave” electrocardiogram pattern during exercise treadmill test: a case report.   J Med Case Rep. 2011;5:304. doi:10.1186/1752-1947-5-304PubMedGoogle ScholarCrossref
5.
Aizawa  Y , Jastrzebski  M , Ozawa  T ,  et al.  Characteristics of electrocardiographic repolarization in acute myocardial infarction complicated by ventricular fibrillation.   J Electrocardiol. 2012;45(3):252-259. doi:10.1016/j.jelectrocard.2011.11.007PubMedGoogle ScholarCrossref
6.
Bao  M , Zhang  J , Huang  C , Jiang  H , Liu  J , Zhao  D .  Abnormal intracellular calcium handling underlying T-wave alternans and its hysteresis.   Cardiology. 2007;108(3):147-156. doi:10.1159/000096566PubMedGoogle ScholarCrossref
7.
Narayan  SM .  T-wave alternans and the susceptibility to ventricular arrhythmias.   J Am Coll Cardiol. 2006;47(2):269-281. doi:10.1016/j.jacc.2005.08.066PubMedGoogle ScholarCrossref
8.
Pastore  JM , Girouard  SD , Laurita  KR , Akar  FG , Rosenbaum  DS .  Mechanism linking T-wave alternans to the genesis of cardiac fibrillation.   Circulation. 1999;99(10):1385-1394. doi:10.1161/01.CIR.99.10.1385PubMedGoogle ScholarCrossref
9.
Moore  PK , Raffel  KE , Whitman  IR .  Macroscopic T-wave alternans: a red flag for code blue.   JAMA Intern Med. 2017;177(10):1520-1522. doi:10.1001/jamainternmed.2017.3191PubMedGoogle ScholarCrossref
AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

Close
Want full access to the AMA Ed Hub?
After you sign up for AMA Membership, make sure you sign in or create a Physician account with the AMA in order to access all learning activities on the AMA Ed Hub
Buy this activity
Close
Want full access to the AMA Ed Hub?
After you sign up for AMA Membership, make sure you sign in or create a Physician account with the AMA in order to access all learning activities on the AMA Ed Hub
Buy this activity
Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close

Name Your Search

Save Search
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Close
Close

Lookup An Activity

or

My Saved Searches

You currently have no searches saved.

Close

My Saved Courses

You currently have no courses saved.

Close