What will happen if you happen to thrombolyse Wellen syndrome?
- Will evolve into STEMI by prothrombotic trigger of lytic agent
- ECG will get normalised with clinical stability in some
- Nothing happens. ECG will remain same.
- Worsen the situation in majority
- Will be severely reprimanded by your consultant and peers.
Answer:
4 will be answer for most of us , while 2 and 3 is a lesser, but distinct possibility. I have never seen 1 happen .Whatever is the correct answer , response 5 will always be correct.
What is the criteria to diagnose Wellen syndrome ?
The criteria used to diagnose Wellen syndrome include symmetric and deeply inverted T waves or biphasic T waves in leads V2 and V3 in a pain-free state, plus isoelectric or minimally elevated (<1 mm) ST segment. In addition, the criteria require the absence of precordial Q waves, the presence of history of angina, and normal or slightly elevated cardiac serum markers.
Wellens is a glorified subset of ACS. It can be referred to as an ACS in a confused state of evolution. Most often a critical mechanical LAD lesion is noted. Thrombus, by no means is excluded. This is the reason some times lytics work. Spasm of epicardial coronary artery is also part of the problem. Since Wellens patients exhibit dynamic symptoms akin to their T waves (often in an inverse relation), it is natural that cardiologists are also tentative, especially if these patients have hypertension and LVH as well.
1.How to manage Wellen syndrome?
Majority of Wellens end up as NSTEMI, statistics tells us about 20% of them can be STEMI in incognito mode demanding lysis or emergency PCI. Since lysis is harmful in subtotal occlusion, it is safe to take all Wellens to cath lab and decide thereafter.
2.Is Wellens exclusive to LAD ?
No. RCA and LCX Wellens do occur, making this entity’s perceived unique importance less certain
3.How common is thrombosis in the culprit artery of Wellen syndrome ?
It is generally believed it is more of a mechanical plaque lesion. However by no means, we can say thrombosis do not occur. This is the reason lytics sometimes work , though we argue it as apparent contraindication.
4.Is there a benign face of Wellen syndrome ?
Yes, we believe so. If Wellen presents as evolved Non -Q-MI or as evolved NSTEMI, a term most cardiologist will not agree with existence of such a terminology .(Clinically, stabilised unstable angina also falls under this category)
Final message
It is curious truth, even fearsome STEMI can be effectively managed without knowing the coronary anatomy (with thrombolysis) ,while Wellen’s a lesser emergency demands more urgent knowledge of coronary anatomy .
Reference
Dr.S.Venkatesan MD 