A 58-year-old man with unstable angina has deep, symmetric T-wave inversions in leads V2-V4 that appear when his chest pain resolves. Troponin is mildly elevated at 0.08 ng/mL. Coronary angiography is planned. What is the most likely coronary anatomy?

• A Critical proximal left anterior descending artery stenosis ✓
• B Critical left circumflex artery stenosis
• C Critical right coronary artery stenosis
• D Left main coronary artery stenosis

Explanation

Wellens syndrome (LAD coronary T-wave inversion) is characterized by deep symmetric T-wave inversions in V2-V4 during pain-free periods, indicating critical proximal LAD stenosis. It is a pre-infarction pattern requiring urgent angiography and revascularization. The T waves appear when pain resolves because they represent reperfusion changes in a territory with threatened infarction.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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