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Ominous Electrocardiographic Patterns in an Older Adult With Chest Pain

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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).

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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).

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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
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