Electrocardiographic transition in wellens syndrome: a common and underrecognized phenomenon

Abstract Wellens syndrome is characterized by two distinct electrocardiographic (ECG) patterns associated with subocclusive stenosis of the left anterior descending artery (LAD). We analyzed 36 patients with Wellens syndrome and assessed if the transition between both patterns is frequent and relevant. (Figure 1). Purpose: To investigate the frequency and clinical significance of the transition from pattern A to pattern B in Wellens syndrome. Methods: Observational study at a university hospital in patients with Wellens syndrome defined by a biphasic component of the T-wave, in leads V2 and V3 (type A), or a deep and symmetric inversion of the T-wave in V2 and V3 (type B), all with confirmed subocclusive stenosis of the left anterior descending artery. We assessed the serial electrographic findings and additionally analyzed the demographics, risk factors, past history, left ventricle ejection fraction (LVEF) and revascularization outcomes. Results:Thirty-six patients with Wellens syndrome were recruited and analyzed. Data of 15 who progressed from patterns A to B can be observed in table 1. Ten of the fifteen patients were males (66%), with a median age of 69 years (interquartile range of 59-72). Most had classical coronary risk factors, and only two did not have any (13%). In our cohort, the most frequent risk factor was smoking (66%) followed by hypertension (60%). Positive troponin levels were observed in twelve of the fifteen patients (80%), leading to a diagnosis of NSTEMI and the other three patients were diagnosed with unstable angina (20%). Left ventricular ejection fraction was preserved in 80%. Five patients (33%) had single vessel disease, seven had two-vessel disease (46%), and three (20%) had multivessel disease. The LAD was affected in all patients, with four (26%) at proximal, six in mid-third (40%), and five (33%) in both territories. Eleven of fifteen patients were revascularized (73%), six of them percutaneously (40%), and five with bypass grafting (33%). The rest four patients were not revascularized by a Heart Team decision. When we studied all 36 cases, we found that 26 had an initial A pattern, and 15 evolved from pattern A to pattern B. These findings denotes an electrocardiographic progression of the same disease. In the entire cohort, the prevalence of pattern B was lower at the initial presentation, probably because many cases are diagnosed at different stages of the disease. Conclusion:Serial electrocardiograms performed on patients with a high clinical suspicion are crucial for diagnosing Wellens syndrome. Transition from pattern A to B is common and likely reflects the natural progression of the disease. Delays in the patient presentation could explain the higher prevalence of the B pattern in other cohorts. While this finding might not modify the approach and treatment, it does highlight the importance of recognizing high-risk ECG patterns and serial changes in acute coronary syndromes.Transition from patterns A to B Characteristics of Wellens Transition