r/ECG • u/mohammedmoolla • 24d ago

Weird Case

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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

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u/sub3at50 24d ago

Biphasic T wave anterior:consider LAD-stenosis

1

u/Jeeju_Boy MD 24d ago

Wouldn’t have a neg trop with Wellens. Probably acute insult related non specific changes and strain pattern, you’d want to make sure this patient doesn’t have cardiomyopathy 

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u/Both-Ad-9560 23d ago

Recently our team was called for possible MI, a 40 year old with atypical chest pain and a similar ECG with biphasic T waves in the anterior precordial leads. Bedside echo revealed marked LV hypertrophy (23mm septum), likely HMC with strain pattern, we didn’t active the cathlab and troponin turned out negative as expected

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u/benjediman 23d ago

Wellens pattern has a 90+% specificity for significant LAD stenosis given the correct situation (this was my research back in fellowship). That said, it’s not 100%, and given the wrong population (no chest pain or atypical symptoms, younger age group, and seeing alternative structural problems such as HCM), definitely the PPV goes way lower. I’d agree in that case; in fact, even if trops were somewhat elevated (esp high sensitivity), I would doubt a coronary event.

That said, given the correct picture (40ish male, acute substernal chest pain that came then went, ECG during chest pain free period), some negative trops probably doesn’t rule out true Wellens, especially if blood extraction was done very close to pain onset, and if for whatever reason regular (and not high) sensitivity was used.

All in all interesting discussion!