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Case #30

You are in the CCU and are covering your colleague for the week end. One of his patients just had an MI and you are looking through the chart and are interested in how he presented and what the EKG looked like. Can you tell simply from this EKG where the culprit lesion is?

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From this EKG you can predict what will be seen on Coronary Angiography So from the beginning, we have Sinus Rhythm, left atrial enlargement from the p morphology in V1, left axis deviation due secondarily to the Massive ACUTE ST ELEVATION MI localized by the ST Elevations in v2 through v5 which would be labeled "Antero-Lateral". But what is more important to notice on this EKG is the specific ST-Twave changes in v2-v3 which are labeled "Wellens Warning" or "Wellen's Sign" which represent Left Anterior Descending (LAD) artery stenosis/thrombosis.

Figure 1.

In Figure 1 you can see the black arrows pointing to the specific ST-T wave findings that are labeled "Wellen's Warning" or "Wellen's Sign" which are present in our patients EKG.

This characteristic pattern was well reported in an article by Wellens and colleagues in 1962 in the American Heart Journal (Am Heart J 103:730, 1962) and was found to represent Critical Left Anterior Descending artery stenosis. Also found to represent impending stenosis if no ST-Elevations where present yet.

When examining patients for the first time with any type of unstable angina or chest pain symptoms with no ST changes but Wellen's warning present should not be taken lightly but aggressively pursued to rule out Ischemia.

Figure 2 is an example of a patient who presented with chest pain with no other EKG changes but these and went on to have a Massive MI due to a lesion of the LAD. So Even if there are no ST elevations this characteristic finding in v2 and v3 should not be over looked.

Figure. 2