A 54-year-old man presents to the emergency department with 30 minutes of chest pain that has now completely resolved. He has no ongoing discomfort and is haemodynamically stable. ECG shows deep, symmetrically biphasic T waves in leads V2 and V3 with preserved R-wave progression and no ST elevation. Initial high-sensitivity troponin is within normal limits. What is the most appropriate next step?
- A Discharge home with outpatient follow-up
- B Treadmill exercise stress test before deciding on further management
- C Immediate coronary angiography ✓
- D Serial ECGs for 24 hours without antiplatelet therapy
Correct answer: C. Immediate coronary angiography
Explanation
Wellens syndrome type A (biphasic T waves in V2-V3) or type C (deeply inverted T waves) indicates critical proximal LAD stenosis with a stunned but viable myocardium. The pain-free window with normal troponin is typical, and the patient is at high risk of extensive anterior STEMI. Exercise stress testing is contraindicated because it can precipitate catastrophic occlusion, and discharge leaves a critical lesion untreated.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.