Important Electrocardiographic Changes in the Absence of Positive Cardiac Biomarkers

Scenario: A 62-year-old woman arrives in the emergency department complaining of shortness of breath with transient chest pain. She has no significant medical history and mentions that she has suffered with these “attacks for years” but was more worried this morning. She is hemodynamically stable and her presenting electrocardiogram (ECG) is shown below.

Sinus bradycardia with Wellens syndrome suggesting acute coronary syndrome.

The rhythm of this ECG is normal; however, during repolarization, the T waves in the precordial leads (V₃ through V₆) are abnormal. This pattern is referred to as Wellens syndrome. Wellens syndrome is an ECG indicator of a potentially critical stenosis in the proximal left anterior descending (LAD) coronary artery in patients with unstable angina. This evolving ECG pattern begins with biphasic T waves (as seen here), where half of the T wave is above the isoelectric line and the other half is below...