The Second Affiliated Hospital of Wenzhou Medical College Wellens syndrome 温州医学院附属第二医院杨鹏麟

The Second Affiliated Hospital of Wenzhou Medical College

Wellens syndrome

温州医学院附属第二医院杨鹏麟


Pain free and in VT?

“Can you take a look at the patient in bed 6?

I think he is having runs of VT!”

Pain free and in VT?


Pain free and in VT?You are called to the monitored area in ED to see a 62-year man who is awaiting a bed under the medics for investigation of an episode of chest pain earlier in the day. He is currently pain free, sat up in bed looking undistressed with a blood pressure of 150/90. The monitor shows intermittent runs of a broad complex rhythm.His ECG is shown below:


ECG


Questions

Q1. What is the electrophysiological basis for the broad

complex rhythm?

Q2. What treatment is required for the broad complex rhythm?

Q3. What is the clinical significance of the other ECG changes?

Q4. How should this patient be managed?


ECG


Q3 What is the clinical significance of the other ECG changes?

In a patient presenting with recent chest pain, an ECG

showing biphasic or deeply inverted T waves in leads V2-4 is

highly specific for a critical occlusion of the proximal LAD.

These patients may be pain free by the time the ECG is taken

and have normally or minimally elevated cardiac enzymes;

however, they are at extremely high risk for extensive anterior

wall MI within the next 2 weeks.


Q4 How should this patient be managed?

This patient needs urgent cardiology referral, admission to a

monitored bed and early PCI (ideally within 48 hours). Medical

management (including thrombolysis) is frequently ineffective

in this condition. The only way to prevent progression to

extensive anterior MI is revascularization via PCI or CABG.


Result of CAG


Wellens syndrome 1982

Am Heart J 1982;103:730-6


近期有胸痛发作（约 20-30分钟）在 V2-V3 导联出现特征性 T 波改变（无症状时记录的 ECG）无明显 ST段偏移（无症状时）无 QRS波形态改变心肌标志物可正常或轻度增高部分患者可出现左室运动障碍

Wellens 综合症诊断标准


Wellens 综合症 T波两种不同的表现形式

Type 1 Type 2


Wellens 综合症造影结果

LAD 近端 50-99% 不稳定病变，极易进展为急性 ST 段抬高的广泛前壁心梗


Wellens 综合症的意义在于早期识别 LAD 近端的不稳定病变，此类患者极易在 2 周内进展为急性 ST 段抬高的广泛前壁心梗（ 75% ），应尽早行 PCI 。一旦发生急性闭塞，即使争分夺秒地行急诊 PCI 也只能挽救部分心肌，对于那些即将发生急性闭塞的病变早期识别和及时处理，避免一次 STEMI 是非常有意义的。这时候行 PCI 成功率高，并发症少，对病人价值最大。


Part VI: Acute Ischemia/Infarction

In patients suspected of having ACS on clinical grounds, marked (greater than or equal to 2mm symmetrical precordial T-wave inversion strongly suggests acute ischemia, particularly that due to a critical stenosis of the left anterior descending coronary artery (LAD). Patients with this ECG finding are at high risk if given medical treatment alone. Revascularization will often reverse both the T-wave inversion and wall-motion disorder.


Some studies have cast doubt on the prognostic value of isolated T-wave inversion.However, deep symmetrical inversion of the T-waves in the anterior chest leads is often related to a significant stenosis of

the proximal left anterior descending coronary artery or main stem.

Guidelines for the diagnosis and treatment ofnon-ST-segment elevation acute coronary syndromes

European Heart Journal (2007) 28, 1598–1660doi:10.1093/eurheartj/ehm161

2007 ESC Guidelines


Wellens 综合症带来的思考 1 、 ACS 持续胸痛 5 小时患者的心电图 2 、持续胸痛 1 小时患者的心电图3 、院外持续胸痛 1-2 小时，就诊时胸痛已缓解4 、反复胸痛，每次持续 20-30 分钟，就诊时无胸痛5 、反复胸痛，每次持续 5-10 分钟，就诊时无胸痛

在一些缺血发作时间短， QRS 波、 ST 段及 TnI

无明显变化的患者身上如何寻找 ACS 的线索？


Wellens 综合征的机制

持续缺血时间的长短决定 ECG 形态的演变

急性 STEMI 的演变


心肌缺血再灌注血流中断 5min 时，心肌处于可逆性损伤，心肌灌注迅速恢复后，缺血心肌已形成的各种功能的损伤可以快速、完全性恢复。当血流中断 15-30min 时，缺血造成的心肌功能障碍明显加重，此时发生再灌注时，已发生的心肌细胞代谢、电生化等功能障碍常需数小时 - 数天甚至更长时间才能完全恢复，这种心肌功能延迟恢复的现象称为心肌顿抑。超过 30min 时以上时，则可造成心肌细胞不可逆的缺血、坏死。


Wellens 综合症带来的启示在一些缺血发作时间短（ 20-30 分钟）， QRS 波、 ST 段及 TnI 无明显变化的患者身上如何寻找 ACS 的线索？通常这些患者在胸痛发作后数小时 - 数天ECG 存在 T 波的演变。


入院无胸痛时胸痛时Case 1


Lead

V2

V3

V4

胸痛时无胸痛时

The Wellens’ syndrome EKG pattern is usually paradoxically present during a pain-free

state, and can seem to normalize somewhat during ischemic pain.


V1

V1 V5

拇指法则 Rule of thumb

V1

无胸痛胸痛拇指法则

=


CAG 结果

我的策略 -“ 亚急诊 PCI”


Case 2 无胸痛时 ECG


CAG 及 PCI 结果


术后第二天 ECG


术后第 10 天 ECG



未进展为 Q 波的 STEMI

Case 3 胸痛 1h 余 , 已缓解， Wellens T ?

A B C D


Wellens T wave ?

Inverted T waves on electrocardiogram: myocardial ischemia versus pulmonary embolism Sanjay Sarin Journal of Electrocardiology 38 (2005) 361– 363


Wellens T wave ?

Global T-wave inversion in a 77-year-old woman Proc (Bayl Univ Med Cent) 2009;22(1):81–82


Negative T wave


心尖肥厚性心肌病


3 种常见 T 波倒置的特点 V2 V3 V4

缺血性 T 波

脑血管意外

心尖肥厚性心肌病

7th Braunwald's Heart Disease 134


T wave Inversion

Electrocardiographic T-wave changes underlying acute cardiac and cerebral events John N. Catanzaro American Journal of Emergency Medicine (2008) 26, 716–720

S1Q3T3Deep and splayed

Variant in PregnancyPulmonary Embolus

Prolonged QT interval Normal QT interval

Cerebrovascular Accident

Subarachnoid Hemmorhage

Digoxin Effect

Nonconvulsive status Epilepticus

Pulmonary Embolus

Myocardial stunning

Myocardial infarction

Subendocardial infarction

Wellens Syndrome

Left Ventricular Strain

Athletic heart syndrome

Normal Variant “Adolescent”


A case of sudden death due to ???


Title in here

This is Wellen’s warning



The Second Affiliated Hospital of Wenzhou Medical College08 ESC STEMI Guideline


2010 ESC Guidelines on myocardial revascularization

Documents

The Second Affiliated Hospital of Wenzhou Medical College Wellens syndrome 温州医学院附属第二医院 杨鹏麟

The Second Affiliated Hospital of Wenzhou Medical College Wellens syndrome 温州医学院附属第二医院杨鹏麟