A 52-year-old man admitted for chest pain is currently pain free. His ECG shows deeply symmetric inverted T waves in leads V2 and V3 with minimal ST segment changes and no Q waves. Cardiac troponin is mildly elevated. The cardiology registrar plans to send him for an exercise treadmill test. What is the most appropriate advice regarding this plan?

• A Cancel stress testing and arrange urgent coronary angiography ✓
• B Proceed with treadmill testing to stratify his risk
• C Discharge him with outpatient follow-up in 6 weeks
• D Perform a dobutamine stress echocardiogram instead

Explanation

This is Wellens syndrome, defined by characteristic biphasic or deeply inverted T waves in V2 and V3 in a pain-free state with preserved R-wave progression. It signals critical proximal LAD stenosis with hibernating myocardium. Stress testing is contraindicated because provoking ischemia can trigger anterior infarction or arrhythmia. These patients need early invasive angiography, and most show tight proximal LAD lesions at catheterization.

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.