August 29, 2013

ECG: Wellen or just Post MI Changes?

This 40+ years old gentleman with history of MI and angiogram with stenting done earlier this year. Being told to have  three vessel disease. Otherwise, NYHA II and no failure symptom. Having on and off shortness of breath and no typical chest pain. Occasional episode of stable angina, relieve by sublingual GTN. He was on anti platelet and anti failure medication as well..

 ECG shows sinus rhythm with normal axis deviation

T inversion of lead I, AVL, and V2-V5 (biphasic deep T inversion)

Deep Q wave and poor R wave progression in lead V1-V3

Another striking feature is the present of saddle shape ST elevation at the inferior lead which could be interpreted as acute ST elevation myocardial infarction. Upon browsing the patient’s old history. The finding was already there and did not return to baseline after streptokinase.

So my impression is possible Wellen syndrome Type 2 with old Anteroseptal and ? lateral and inferior infarct as well. Wellen syndrome is associated with critical stenosis of proximal left anterior descending (LAD) coronary artery. And patient have high risk of developing MI.

Few question rise in this case.

1. Can Wellen syndrome present with any QRS complex abnormality as the original description by Hein J. J. Wellens and colleagues in 1982 states that the ECG should be without Q waves, without significant ST-segment elevation, and with normal precordial R-wave progression

Another criteria for Wellen syndrome includes

a. Characteristic T-wave changes (symmetrical, often deep >2mm, T wave inversions in the anterior precordial leads). Uniphasic T inversion in Wellen I and biphasic T inversion in Wellen II.

b. History of angina chest pain

c. Normal or minimally elevated cardiac enzyme levels

2. Since patient is on stenting. Is it possible that this ECG representing blocked stent.

3. How urgent is urgent that the patient need angiogram. Is there any way to predict the timing of full blown myocardial infarction. Study indicates that estimated time to develop full blown MI is 8.5 days. With patient already on anti platelet and anti failure medication, should patient be pushed for really emergency angiogram?

No comments:

Post a Comment

Ya Allah! Permudahkanlah aku untuk menuntut ilmuMu, memahaminya, mengingati dan menyebarkannya. Berkatilah ilmu itu dan tambahkanlah ia. Amin.