Is there Wellens’ syndrome in left bundle branch block? Or in inferior and lateral leads?

Written by Pendell Meyers, with edits by Steve Smith

A male in his 80s old had acute onset of chest pain.  Here is his first ECG, time zero:

What do you think?

Sinus rhythm with left bundle branch block. There is concordant STE in leads II, V5, and V6. It may not reach a full millimeter, but the QRS is so small that we should make an exception here. It is proportionally large concordant ST elevation!

The cath lab should be activated, but apparently it was not.  Instead, another ECG was recorded at time 46 minutes:

Now there is more than 1 mm of concordant ST elevation in leads II, V5, and V6.
In addition, there is now excessively proportionally discordant (more than 25% of preceding S-wave) in leads III, and aVF.
So there is a definite inferior and lateral MI.  There is no ST depression in lead I, which suggests a circumflex lesion as the culprit.

The cath lab was activated and a circumflex occlusion was opened and stented, with a door to balloon time of 3 hours.

Here are ECGs recorded after reperfusion:

ST deviation has resolved. There is already terminal T-wave inversion in leads III and aVF.
T-waves are inverting in the affected leads.
This is analogous “Wellens’ waves” of the inferior and lateral leads, in the presence of LBBB!

As an explorative substudy of our validation of the modified Sgarbossa criteria, we studied T-wave inversion. We looked at serial ECGs on patients with acute coronary occlusion ACO) who underwent reperfusion and compared to serial ECG on patients without ACO. Unfortunately, as a result of our multisite study in which ACO came from many institutions and controls from one institution, only 6 of 45 patients with ACO and reperfusion had serial ECGs available, and all 245 patients without ACO had serial ECGs available.

When this pattern was retrospectively defined as being either 1) present in at least two
contiguous anterior or inferior leads in at least two consecutive ECGs prior to reversal or 2) deeper than 3 mm in two contiguous leads (requiring only one ECG), it was found to be predictive of reperfused ACO (either spontaneously prior to catheterization or with mechanical reperfusion) with derived sensitivity and specificity of 5 of 6 [83% (95% CI 36–99%)] and 241 of 245 [98% (95% CI 96–99%)]. This is preliminary low-level evidence which suggests that terminal T-wave inversion as a sign of reperfusion is sometimes still applicable in the setting of abnormal QRS such as LBBB and likely ventricular paced rhythm as well.

Meyers HP.  Jaffa E.  Smith SW.  Drake W. Limkakeng AT.  Evaluation of T-Wave Morphology in Patients With Left Bundle Branch Block and Suspected Acute Coronary Syndrome.  Journal of Emergency Medicine 51(3):229-237; September 2016.

We (Meyers and Smith) also published a case of Wellens’ syndrome (involving the LAD) in LBBB:

Dynamic T-wave inversions in the setting of left bundle branch block

As a very brief review for new readers, terminal T-wave inversion is an expected finding with reperfusion of acute coronary occlusion which is well established in the presence of normal QRS conduction (no LBBB, paced rhythm, etc). It was first described by Wellens and colleagues in the anterior leads in the setting of an acute proximal LAD stenosis, and later it was more fully understood as a transient phase of reperfusion soon after acute coronary occlusion. When it was first described, it was initially divided into “pattern A” and “pattern B”, characterized by biphasic terminal T-wave inversions then full, symmetric T-wave inversions, respectively. In reality these are not separate presentations of the disease but simply two different time periods during the progression (see progression below).

Furthermore, though Wellens described this pattern only in LAD leads, it is clear that it occurs in inferior and lateral leads as well.
See this case of inferolateral Wellens’ syndrome, with subsequent re-occlusion and pseudonormalization of T-waves.

See this post: Classic Evolution of Wellens’ T-waves over 26 hours

See these posts for Pseudonormalization of Wellens’ waves (re-occlusion):

This one is EXTREMELY subtle: 

A Middle-Age Male with Chest Pain that Recurs in the ED

Pseudonormalization of Wellens’ Waves

Subtle LAD Occlusion with Pseudonormalization of Wellens’ Waves.

This one shows why patients with Wellens’ syndrome who do not go immediately to the cath lab need continuous 12-lead ST Segment monitoring:

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