A 48-year-old man presents to the emergency department with a 30-minute episode of severe retrosternal chest pain that has now resolved completely. He has a history of similar episodes at rest over the past week. ECG taken while he is pain-free shows deep symmetric T-wave inversions in leads V2 and V3 with a biphasic T wave in V4. There is no ST elevation and no Q waves. Cardiac enzymes are normal. Coronary angiography is most likely to show which of the following?
- A Critical proximal left anterior descending artery stenosis ✓
- B Normal coronary arteries with coronary vasospasm
- C Occlusion of the right coronary artery
- D Severe three-vessel disease with preserved flow
Correct answer: A. Critical proximal left anterior descending artery stenosis
Explanation
This is Wellens syndrome (type A biphasic or type B deeply inverted T waves in V2-V3 on a pain-free ECG with normal or minimally elevated enzymes). It represents critical stenosis of the proximal LAD with a stunned but viable anterior wall. These patients are at very high risk of extensive anterior infarction if subjected to stress testing, so early angiography is indicated. Vasospasm gives transient ST elevation during pain, not this fixed precordial T-wave pattern.
Reference: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 12th ed.
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Written and medically reviewed by the StethoPrep medical team.