ECG Wellen's sign and Widow maker sign presentation

Editor's Notes

1. I hope it is fair to say that beyond basic concept of ECG interpretation it becomes insanely difficult. I would like to talk to you in next 10 min or so about some ECG changes which I only found out about once I became FY1. I suppose like most of people I had been busy learning how to recognise acute coronary syndrome and how to treat it. Since start of FY1 I’m seeing various ECGS on daily basis and quite often no one on ward is able to make any sense of the reading. Then we try to contact cardiologist which all you know how difficult it can be at times. ECG is readily available test at the bedside which requires good interpretation skills – which in turn can save someone's life. I would like to present here two perhaps less common signs on ECG of which immediate recognition can avert further deterioration.
2. 46yo male Admitted to AE with 12h intermittent chest pain Once you get to the patient, he feels fine and the pain has gone. You decide to do ECG
3. Anything striking? So we have a patient abnormal T waves in precordial leads from V1 to V4, with no chest pain and –ve TNI This kind of picture is known to be a Wellen’s Syndrome or Wellen’s Warning described by Dutch Dr Wellen himself about 30 years ago
4. It’s a T wave abnormality only present during pain free period, Classically present in precordial leads but also can sometimes expand to other leads. ST usually is normal Highly specific of critical obstruction in LAD Appears before infarction begins – hence initially –ve TNI and no STMI Patients are at high risk of MI The evidence suggest that the mortality risk is 75% within one week. And the patients will require most-likely PTCA management as the Medical management doesn’t work for these big lesions
5. Just quick look at two different morphology variants of Wellen’s Sign 1st type is no brainer it looks like obvious T-wave inversion. Type 2 is more tricky one as it is not uncommon for ECG machine to be recognised by as non-specific or even normal pattern So if anything please bear in mind how does the type to Wellen’s sign looks like
6. High voltage QRS can produce abnormal T waves. As it can happen in LVH strain. Where we have high amplitude QRS in V4-V6 and Deep S wave in V1
7. Brugada syndrome Described by Brugada’s brothers at beginning of 1990s Previously known as Sudden unexplained nocturnal death Relatively common cause of sudden death in young Asian men with mean age of 41. Some variants have genetic mutation of Na channel which causes abnormal conduction. It is second leading cause of death in young males before 40s right after trauma.
8. So quick recap Wellen syndrome is manifested by inverted or biphasic T-waves in precordial leads during pain free period. There is high chance that the patient has occlusion of proximal LAD which combined with intermittent chest pain can prelude MI Patient is very likely to require PTCA If in doubt do series of ECGs Be weary of negative troponins as infarction might be impending very soon – hence repeat ECG!
9. aVR covers right upper side of heart It gives reciprocal information of aVL, lead II and V4-V6 That’s why some cardiologist used to argue that aVR was redundant as it was not giving any new information. However there is more research coming up in recent years showing evidence that ST elevation in aVR specifically indicated critical coronary artery stenosis. Especially if the elevation is over or equal 1mm, when elevation is higher in comparison to V1
10. STE in aVR equal or greater than 1mm means that LMCA is almost certain and the mortality is as high as 70% due to cardiogenic shock or lethal arrythmia. Medical Rx including lytics don’t improve the outcome. Emergency PTCA reduces mortality to 40%. Ultimately the patient is very likely to need CABG, Prior to giving clopidogrel or wasting time on any other medical treatment we should discuss with cardiologist. If patient who requires PTCA or CABG probably shouldn’t be given clopidogrel.
11. If you haven’t please check out this excellent resources! Dr Mattu makes amazing short ECG presentations – lot of my inspiration came from him! Life in the fast line has everything you need to learn about spotting life threatening ECG abnormality. It also has very good articles on many other acute conditions.