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02-08-2018 | Rhythm Puzzle – Answer | Uitgave 9/2018 Open Access

Netherlands Heart Journal 9/2018

A peek behind the curtain

Netherlands Heart Journal > Uitgave 9/2018
M. Kamali-Sadeghian, P. T. G. Bot, R. Tukkie, H. J. Wellens, D. J. van Doorn


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 ...

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