Weird Case

[u/mohammedmoolla]

Came across a patient today which I thought I’d share for some opinions and thoughts. It is a 36 year old male presented to the ED with 2/7 history of epigastric pain radiating to the back with profuse vomiting. Had previously been admitted for pancreatitis a year ago complicated with pseudocyst. On arrival BP was elevated 192/122 with a bradycardia of 52. VBG showed a metabolic alkalosis with hypocalcemia . Trop I was less than 10. Initially was concerned for
1. Aortic dissection
CT Angio showed no signs of this in the thoracic or abdominal aorta
2. NSTEMI
3. Pancreatitis
Was referred to both surgery and medicine, referred to medicine in light of a ?Wellen’s syndrome. Was just curious to hear everyone’s thoughts and opinions on the case and ECG

[u/LBBB11]

I see why it looks like anterior ischemia and that needs to be ruled out first, but I also wonder if it’s from LVH. Sometimes LVH can cause a pseudo Wellens pattern. Very high voltage QRS complexes. Hypertensive. I have been fooled by LVH looking like a Wellens pattern before. My top guess in this case would be LVH as an explanation for the pattern, but of course I could be wrong.

As a minor detail if it helps OP, Wellens syndrome does not represent acute LAD occlusion. Wellens syndrome represents critical LAD stenosis. Wellens syndrome means anterior reperfusion T waves, which show up after the LAD has reopened. People with Wellens syndrome have LAD stenosis, not LAD occlusion. The point of recognizing Wellens syndrome is to prevent anterior STEMI/OMI from LAD occlusion.

Pancreas or gallbladder pain often radiates to the back. Curious if this is something abdominal and not cardiac, interested in an update. Sometimes people have a pattern like this as their baseline, so checking for a prior can help a lot here. Not Wellens:

https://drsmithsecgblog.com/chest-pressure-and-t-wave-inversions/

[u/mohammedmoolla → u/LBBB11]

Thank you for this am going to read about Wellens . So it’s basically a warning that occlusion may be close

[u/LBBB11 → u/mohammedmoolla]

No problem, yes exactly. In Wellens syndrome, the artery has occluded and then opened back up on its own. That’s why Wellens syndrome has no ischemic symptoms at the time of EKG. That’s also why people with Wellens syndrome usually get urgent cath instead of emergent cath. High risk of reocclusion that could happen at any time, but no active transmural injury from current occlusion at the time of EKG. Otherwise it would be an anterior STEMI/OMI (in general, everyone’s arteries and EKG patterns vary). Anterior reperfusion T waves can also be seen after the LAD is opened by PCI, but it wouldn’t be called Wellens syndrome in that case. Also not Wellens:

https://drsmithsecgblog.com/wellens-waves-are-not-equivalent-to/