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Gepubliceerd in: Netherlands Heart Journal 9/2018

Open Access 02-08-2018 | Rhythm Puzzle – Answer

A peek behind the curtain

Auteurs: M. Kamali-Sadeghian, P. T. G. Bot, R. Tukkie, H. J. Wellens, D. J. van Doorn

Gepubliceerd in: Netherlands Heart Journal | Uitgave 9/2018

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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 anteroseptal leads. Furthermore, precordial ST-segment deviation, pathological Q waves and poor R‑wave progression should be absent. These ominous T‑wave inversions mostly occur in patients with a history of angina in a pain-free period, 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 resulting in characteristic inversed or biphasic T waves [3]. Interestingly, the present ECG shows that the typical Wellens’ pattern only occurs after a long R‑R interval and thus a prolonged diastolic filling time, whereas rather short R‑R intervals are followed by normalised T waves. This phenomenon is presumably explained by the intermittent increase in left ventricular end-diastolic pressure impairing coronary perfusion and causing maximal ischaemia during contraction after a long R‑R interval with a large stroke volume.
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.
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Netherlands Heart Journal

Het Netherlands Heart Journal wordt uitgegeven in samenwerking met de Nederlandse Vereniging voor Cardiologie en de Nederlandse Hartstichting. Het tijdschrift is Engelstalig en wordt gratis beschikbaa ...

Literatuur
1.
go back to reference de Zwaan C, Bar FW, Wellens HJ. Characteristic electrocardiographic pattern indicating a critical stenosis high in left anterior descending coronary artery in patients admitted because of impending myocardial infarction. Am Heart J. 1982;103:730–6.CrossRefPubMed de Zwaan C, Bar FW, Wellens HJ. Characteristic electrocardiographic pattern indicating a critical stenosis high in left anterior descending coronary artery in patients admitted because of impending myocardial infarction. Am Heart J. 1982;103:730–6.CrossRefPubMed
2.
go back to reference Rhinehardt J, Brady WJ, Perron AD, Mattu A. Electrocardiographic manifestations of Wellens’ syndrome. Am J Emerg Med. 2002;20(7):638–43.CrossRefPubMed Rhinehardt J, Brady WJ, Perron AD, Mattu A. Electrocardiographic manifestations of Wellens’ syndrome. Am J Emerg Med. 2002;20(7):638–43.CrossRefPubMed
Metagegevens
Titel
A peek behind the curtain
Auteurs
M. Kamali-Sadeghian
P. T. G. Bot
R. Tukkie
H. J. Wellens
D. J. van Doorn
Publicatiedatum
02-08-2018
Uitgeverij
Bohn Stafleu van Loghum
Gepubliceerd in
Netherlands Heart Journal / Uitgave 9/2018
Print ISSN: 1568-5888
Elektronisch ISSN: 1876-6250
DOI
https://doi.org/10.1007/s12471-018-1138-9

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