ACUTE PULMONARY EMBOLISM MASQUERADING AS WELLENS’ SYNDROME

Abstract

Background: Wellens' syndrome describes a pattern of ECG changes, particularly deeply inverted or biphasic T-waves in leads V2-V3, associated with critical left anterior descending (LAD) stenosis. Recognition of this pattern and the risk of impending anterior myocardial infarction is vital and definitive treatment typically involves cardiac catheterization with percutaneous coronary intervention. Case: A 54-year-old man with no history of coronary disease presented with two weeks of worsening anginal chest pain which had resolved by time of arrival. Vital signs were all within normal limits. Serial troponins were negative, but ECG demonstrated precordial biphasic T-waves (Figure A). Workup and therapy for critical LAD stenosis was initiated. However, echocardiography showed dilation of the right ventricle with McConnell's sign, and subsequent CT pulmonary angiography demonstrated large saddle pulmonary embolus (PE) with extension into all lobar arteries (Figure B). Decision-making: While the precordial T-wave changes typical of Wellens' syndrome typically indicate a critical coronary lesion, pulmonary embolism with right ventricular strain can also cause these findings. Conclusion(s): Review of the literature reveals that presence of an inverted T-wave in leads III and V1 and peak negative T-wave in V1-V2, as seen in this case (Figure A), should prompt strong consideration of PE in the differential. [Formula presented]Copyright © 2022 American College of Cardiology Foundation