C43-51 Wellens-Like ECG Patterns Revealing Multivessel Coronary Artery Disease and Severe Left Ventricular Dysfunction: A Case Series

Abstract Introduction Wellens syndrome is a pre-infarction electrocardiographic pattern characterized by biphasic or deeply inverted T-waves in the anterior leads during a pain-free state, minimal biomarker elevation, and critical proximal left anterior descending (LAD) stenosis. Recognition is crucial because missed diagnosis may precede large anterior myocardial infarction. We describe two patients exhibiting Wellens-like ECG patterns that diverged from this classic presentation and instead signaled extensive ischemic and systemic atherosclerotic disease. Case Report Case 1: A 70-year-old woman with hyperlipidemia and chronic tobacco use presented with substernal chest pain radiating to the arm and elevated high-sensitivity troponin (229 ng/L). ECG showed deep symmetric T-wave inversions in V2-V6 (Type B Wellens-like pattern). Echocardiography revealed left-ventricular ejection fraction 25-30%. Coronary angiography demonstrated critical 90-95% LAD stenosis with obstructive right and circumflex disease and diffuse calcific atherosclerosis. Additional imaging uncovered subclavian steal and bilateral iliac artery stenoses. Due to prohibitive surgical risk, she underwent staged percutaneous coronary interventions (PCI) of the LAD and RCA. Case 2: A 55-year-old physically active man with hypertension presented with progressive exertional chest pressure advancing to rest. ECG showed Q-waves V₁-V3 and biphasic T-waves V2-V3 extending to V6 (Type A Wellens-like). Troponin was 180 ng/L; echocardiography demonstrated preserved EF 60-65%. Angiography revealed a critical 99% mid-LAD stenosis with TIMI II flow. He underwent successful drug-eluting stent placement under intravascular ultrasound guidance with complete symptom resolution and enrollment in cardiac rehabilitation. Discussion Both cases expand the spectrum of Wellens presentations. Unlike the pain-free, minimally elevated-biomarker phenotype, these Wellens-like patterns appeared during active ischemia and correlated with either multivessel coronary disease and systemic atherosclerosis (Case 1) or an isolated high-risk LAD lesion (Case 2). Persistent deep or biphasic T-wave inversions in symptomatic patients should prompt immediate invasive evaluation even when criteria for “classic” Wellens are not fully met. Recognition of such atypical variants can expedite revascularization, avert inappropriate non-invasive testing, and improve outcomes. Conclusion Wellens-like ECG patterns may indicate ongoing myocardial injury or multivessel disease, not merely pre-infarction LAD occlusion. Early catheterization and individualized revascularization are essential to prevent catastrophic anterior myocardial infarction and to optimize recovery. This abstract is funded by: None