Case 18: Postprandial Pain

A 72 year old female is referred to cardiology for clearance to undergo eye surgery. During her reveiw of symptoms she mentions that she occassionally gets 5-10 minutes of epigastric pain after meals which is always releived by Pepto-Bismol. Below is her EKG taken in the office while she is pain free. She is sent to the ER for further evaluation. A repeat EKG is unchanged and cardiac enzymes are negative. Can she be cleared for surgery or should you recommend a stress-test first?

NEITHER!  This is a trick question.  She needs a cath.

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ANSWER: THIS IS WELLENS’ WARNING

Wellens (1) in 1988, described characteristic EKG findings that are specific for pre-infarction stage in the cardiac muscle supplied by the LAD. Two forms of EKG changes are described:
1- Biphasic T waves in leads v2 and v3. Commonly V1 and V4 are also involved. Occurs in 25%. EKG changes may be subtle
2- Deep T waves in V2-V4. Occurs in 75%. EKG findings not subtle

To further specify his findings Wellens’ described certain criteria that are present with the T wave changes. They are:
-Isoelectric or minimal ST segment elevation (<1mm)
-No precordial Q waves
-History of Angina
-Pain free when EKG pattern noted
-Normal or slightly elevated Cardiac serum markers

In Wellens’ second study (2) all of the patients admitted with these changes had greater than 50% stenosis of the proximal LAD and over 50% had >85% stenosis. The T wave changes are described to last for weeks.

The role of the ER doctor in recognising and acting appropriately is important here. The literature shows case reports of patients arriving with a history of anginal type pain. Who met all of the Wellens’ criteria and were thus deemed safe to stress test. Only to develop large anterior wall MI’s during the stress test.(3,4) These EKG changes in the setting of Wellens’ syndrome suggest that this must be taken as a warning in an otherwise asymptomatic patient. If missed, the patient may be destined for a large anterior wall MI.

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Author of Case 18: Michael Urdang, MD, USC + LAC Emergency Medicine Residency

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For the differential diagnosis of T-wave inversion, EKG findings and much more get a copy of Side-Kick Emergency Medicine

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REFERENCES:

1. de Zwann C, Bar FW, Wellens HJJ: Characteristic electrocardiographic pattern indicating a critical Stenosis high in the left anterior descending coronary artery in patients admitted because of impending myocardial infarction. Am Heart J 1982;103:730-736
2. de Zwann C, Bar FW, Janssen JH et al: Angiographic and clinical characteristics of patients with unstable angina showing an ECG pattern indicating critical narrowing of the proximal LAD coronary artery. Am Heart J. 1989;117:657-665
3. Tandy TK, Bottomy DP, Lewis JG. Wellens Syndrome. Ann Emerg Med. 1999 Mar 33 (3):347-351
4. Rhinehardt J, Brady WJ, Perron AD and Mattu A. Electrocardiographic manifestation of Wellens’ syndrome. American J of Emerg Med. 20(7):638-643

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