65 yo F w/ hx HTN, GERD, presents to the ED w/ non-exertional intermittent chest pain x4 days, dyspnea on exertion x2 days and nausea x1 day. Trying Prilosec and Tums. ECG below. 

ECG concerning for Wellen’s pattern, new TWI in V2 and biphasic T wave in V3 

324mg ASA chewable given shortly after ED evaluation

IV heparin gtt and ticagrelor 180mg load (then 90mg BID) after cardiology consult 

0hr HS trop 105

STAT echocardiogram w/ apical, mid inferoseptal and inferolateral hypokinesis w/ LVEF 40%

Urgent cardiac catheterization: acute thrombotic stenosis ruptured plaque in proximal LAD; successful PCI

Wellen’s syndrome: 

Associated w/ critical, proximal LAD artery stenosis 

Syndrome - T wave changes w/ anginal chest pain w/o serum marker abnormalities 

ST/T wave normalize or develop in STE during chest pain 

No precordial Q waves and significant ST elevation 

Cardiac serum markers normal or minimally elevated 

Two patterns in lead V2 and V3 (can have changes in V1 and V4) 

1. Isoelectric or minimally STD (<1mm) w/ inverted T wave and/or
2. Biphasic T waves 

Reference: 

Rhinehardt J, Brady WJ, Perron AD, Mattu A. Electrocardiographic manifestations of Wellen’s syndrome. Am J Emerg Med. 2002 Nov: 20(7):638-43. DOI: 10.1053/ajem.2002.34800