A 51-year-old man admitted for resolving chest pain has a baseline ECG showing deep symmetric T wave inversions in leads V2 and V3 with slight coved ST segments. Cardiac troponin is minimally elevated. Bedside echocardiography shows anterior wall hypokinesis with ejection fraction of 45%. What does this pattern signify?

• A Benign repolarization variant requiring no further workup
• B Pericarditis with typical stage 1 changes
• C Occlusive thrombus suitable for immediate fibrinolysis
• D Critical stenosis of the proximal left anterior descending artery ✓

Explanation

Deep symmetric precordial T inversions or biphasic terminal T inversions in V2 and V3 constitute Wellens syndrome, which signals critical proximal LAD stenosis in a patient whose pain has subsided. These patients have a high rate of anterior wall infarction if subjected to exercise stress testing, which is contraindicated; they need angiography. Pericarditis shows diffuse concave ST elevation, not localized deep T inversion.

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

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Written and medically reviewed by the StethoPrep medical team.