A 52-year-old man with episodes of exertional chest pain now presents after pain that resolved spontaneously 40 minutes ago. Troponin is mildly elevated. ECG shows deep, symmetrically inverted T waves in V2 and V3 with preserved R-wave amplitude and no pathological Q waves; there is no significant ST deviation. Which of the following is the correct management?
- A Exercise treadmill stress testing before discharge
- B Discharge on antianginals with outpatient follow-up
- C Urgent coronary angiography without any form of stress testing ✓
- D Dobutamine stress echocardiography to localise ischaemia
Correct answer: C. Urgent coronary angiography without any form of stress testing
Explanation
Deep symmetric T-wave inversion in V2 and V3 with preserved precordial R waves is the Wellens type C pattern, reflecting critical proximal LAD stenosis with a hibernating yet viable anterior wall. The pain-free interval and near-normal ECG are deceptive because the lesion can progress abruptly to anterior STEMI. Any stress modality, especially exercise treadmill testing, risks precipitating fatal arrhythmia or infarction, so urgent angiography is mandatory.
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.