University of Groningen
A peek behind the curtain
Kamali-Sadeghian, M; Bot, P T G; Tukkie, R; Wellens, H J; van Doorn, D J
Published in:Netherlands Heart Hournal DOI:
10.1007/s12471-018-1138-9
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Publication date: 2018
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Kamali-Sadeghian, M., Bot, P. T. G., Tukkie, R., Wellens, H. J., & van Doorn, D. J. (2018). A peek behind the curtain. Netherlands Heart Hournal, 26(9), 469-470. https://doi.org/10.1007/s12471-018-1138-9
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RHYTHM PUZZLE – ANSWER https://doi.org/10.1007/s12471-018-1138-9 Neth Heart J (2018) 26:469–470
A peek behind the curtain
M. Kamali-Sadeghian1· P. T. G. Bot1· R. Tukkie1· H. J. Wellens2· D. J. van Doorn1
Published online: 2 August 2018 © The Author(s) 2018
Answer
The electrocardiogram (ECG) on admission shows atrial fibrillation with slow ventricular response of 42 beats/min. In some QRS complexes, prominent biphasic T waves are seen in the precordial leads V1–V4 (Fig.1). This Wellens’ ECG sign is suggestive of critical proximal left anterior descending (LAD) stenosis [1]. The electrocardiographic features are characterised by either biphasic T waves or the more common deep T-wave inversion in the anterosep-tal leads. Furthermore, precordial ST-segment deviation, pathological Q waves and poor R-wave progression should be absent. These ominous T-wave inversions mostly oc-cur in patients with a history of angina in a pain-free pe-riod, whereas angina can cause “pseudonormalisation” of the T waves [2].
Although the underlying mechanism remains elusive, it has been postulated that myocardial stunning due to oedema causes intramyocardial repolarisation inhomogeneity result-ing in characteristic inversed or biphasic T waves [3]. Inter-estingly, the present ECG shows that the typical Wellens’ pattern only occurs after a long R-R interval and thus a pro-longed diastolic filling time, whereas rather short R-R inter-vals are followed by normalised T waves. This phenomenon is presumably explained by the intermittent increase in left ventricular end-diastolic pressure impairing coronary per-fusion and causing maximal ischaemia during contraction after a long R-R interval with a large stroke volume.
M. Kamali-Sadeghian
mkamalisadeghian@spaarnegasthuis.nl
1 Department of Cardiology, Spaarne Gasthuis, Haarlem, The
Netherlands
2 Department of Cardiology, Maastricht University Medical
Center, Maastricht, The Netherlands
In this patient, an emergent coronary angiogram indeed revealed a subtotal stenosis of the proximal LAD (Fig.2). This lesion was successfully treated with the placement of a drug-eluting stent.
This case underlines that early recognition and urgent revascularisation is imperative in patients with Wellens’ syndrome, as delay in intervention may lead to anterior myocardial infarction [1].
Conflict of interest M. Kamali-Sadeghian, P.T.G. Bot, R. Tukkie, H.J. Wellens and D.J. van Doorn declare that they have no competing interests.
Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http:// creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.
References
1. de Zwaan C, Bar FW, Wellens HJ. Characteristic electrocardio-graphic pattern indicating a critical stenosis high in left anterior de-scending coronary artery in patients admitted because of impending myocardial infarction. Am Heart J. 1982;103:730–6.
2. Rhinehardt J, Brady WJ, Perron AD, Mattu A. Electrocardio-graphic manifestations of Wellens’ syndrome. Am J Emerg Med. 2002;20(7):638–43.
3. Migliore F, Zorzi A, Marra MP, et al. Myocardial edema under-lies dynamic T-wave inversion (Wellens’ ECG pattern) in pa-tients with reversible left ventricular dysfunction. Heart Rhythm. 2011;8(10):1629–34.https://doi.org/10.1016/j.hrthm.2011.04.035.
470 Neth Heart J (2018) 26:469–470
Fig. 1 The arrows indicate the biphasic T waves in the precordial leads appearing after a preceding delay
Fig. 2 Coronary angiography revealing a subtotal stenosis in the prox-imal left anterior descending artery
