Wellens ' syndrome: to stent or not? IVUS negative, Symptoms persist, Stress Testing, Instantaneous Wave Free Ratio, and Fractional Flow Reserve.

A 55 y.o. male with no cardiac PMHX presented for 2 weeks of exertional chest pain, worsened on the day prior to presentation.  On the day of presentation, the chest discomfort was particularly intense, and associated with diaphoresis and nausea.  It was resolved (pain free) when the ECG was recorded:This ECG was read as " nonspecific " by the providers.  What do you think?These is classic Wellens ' pattern A (biphasic, terminal T-wave inversion), and it isWellens 'syndrome (Angina, resolved -- pain free -- with preserved R-waves and Wellens ' pattern A T-waves).  The morphology of these T-waves is very distinct and most T-wave inversion does not fit the pattern.  The pattern manifests a rising ST segment with a sudden fall into the slightly negative T-wave.  If you recognize this pattern, then you are not so dependent on troponin for your diagnosis.  Wellens ' syndrome does notmandate emergent cath lab activation, since the artery is open and the patient is pain free; there is no persistent ongoing ischemia. When the patient was suffering pain prehospital, the artery was occluded, but it spontaneously reperfused (autolysis).  However, the patient is at high risk for re-occlusion at any time and cath lab activation is optimal because this should be considered a transient STEMI in which the ST elevation would have been there had the ECG been recorded during pain.The initial Abbott high sensitivity troponin I was60 ng/...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs