A 48-year-old man presents with 30 minutes of crushing chest pain that has partially subsided at the time of the ECG. Troponin is mildly elevated. The ECG shows deeply inverted, symmetric T waves in leads V2 and V3 with an isoelectric ST segment and preserved R-wave progression. Which of the following is the most appropriate next step?

• A Urgent coronary angiography without any form of stress testing ✓
• B Discharge home with outpatient stress testing
• C Immediate exercise treadmill stress test
• D Serial cardiac enzymes over 48 hours before deciding

Explanation

This is Wellens syndrome (Type B pattern: deep symmetric precordial T-wave inversions in V2-V3; Type A shows biphasic T waves). It reflects critical stenosis of the proximal LAD with spontaneous reperfusion while the artery remains critically narrowed. The myocardium is stunned, not infarcted, so enzymes are often only mildly raised. Exercise stress testing is contraindicated because it can precipitate complete occlusion and extensive anterior infarction; these patients need urgent angiography and revascularization.

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

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.