A 48-year-old man presents to the emergency department with a 40-minute episode of crushing chest pain that has now resolved. He is pain-free on arrival. ECG shows deep, symmetric T wave inversions in V2 and V3 with a biphasic T wave in V4. There is no ST elevation and cardiac biomarkers are minimally elevated. 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 at the crux
- D Diffuse three-vessel disease with preserved flow
Correct answer: A. Critical proximal left anterior descending artery stenosis
Explanation
Wellens syndrome (deep symmetric or biphasic T wave inversions in V2-V3 in a pain-free patient) signals critical stenosis of the proximal LAD with hibernating but viable myocardium. It carries a high risk of extensive anterior infarction, so early angiography is mandatory. Stress testing is contraindicated because it can precipitate a large anterior STEMI. The absence of ST elevation does not make this a benign pattern.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.