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Case Report

'Action potential-like' ST elevation following

pseudo-Wellens' electrocardiogram

Fatih Oksuz, Baris Sensoy, Fatih Sen, Ethem Celik, Ozcan Ozeke *,Orhan Maden

Turkiye Yuksek Ihtisas Training and Research Hospital, Department of Cardiology, Ankara, Turkey

a r t i c l e i n f o

Article history:

Received 8 December 2014

Accepted 29 May 2015

Available online 4 August 2015

Keywords:

Vasospastic angina

ST segment elevation

Wellens' syndrome

a b s t r a c t

Coronary artery vasospasm is an important cause of chest pain syndromes that can lead to

myocardial infarction, ventricular arrhythmias, and sudden death. In 1959, Prinzmetal et al

described a syndrome of nonexertional chest pain with ST-segment elevation on electro-

cardiography. Persistent angina is challenging, and repeated coronary angioplasty may be

required in this syndrome. Calcium antagonists are extremely effective in treating and

preventing coronary spasm, andmay provide long-lasting relief for the patient.Whereas the

Wellens' syndrome is characterized by symmetrically inverted T-waves with preserved R

waves in the precordial leads suggestive of impendingmyocardial infarction due to a critical

proximal left anterior descending stenosis, the pseudo-Wellens' syndrome caused by

coronary artery spasm has also rarely been reported in literature. We present a pseudo-

Wellens syndrome as a cause of vasospastic angina, and a diffuse ST segment elavation on

electrocardiogram resembling the Greek letter lambda, called also 'action potential-like' ECG

in a patient with vasospastic-type Printzmetal angina.

# 2015 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.

1. Introduction

Restingangina isoneof themost frequentsymptomsofpatientsin the emergency room.1 Many patients with chest pain whohave no obstructive stenoses at diagnostic angiography aremisclassified as having noncardiac chest pain.2 Variant anginais a form of angina pectoris that shows transient ST-segmentelevation on electrocardiogram during an attack of chest pain.Ischemic episodes of variant angina show circadian variationand often occur at rest from midnight to early morning.3 Thedemonstration of either spontaneous or provoked coronary

* Corresponding author at: Türkiye Yüksek İhtisas Hastanesi, KardiyoE-mail address: ozcanozeke@gmail.com (O. Ozeke).

http://dx.doi.org/10.1016/j.ihj.2015.05.0250019-4832/# 2015 Cardiological Society of India. Published by Elsevie

spasm proves coronary hypercontractility and thus the diagno-sis of variant angina4 Coronary spasm could be documented innearly 50% of the suspected ACS in emergency departmants.5

Risk stratification of patients with recurrent chest pain andnormal coronary angiogram is a relevant but still definitelyunsolved clinical problem.6 Although coronary artery vaso-spasm can be suspected clinically, proof cannot usually beobtained by non-invasive means but is easily available duringcardiac catheterization. Patients with vasospastic angina arerepeatedly exposed to this invasive procedure as mostcardiologists suspect a coronary lesion (requiring intervention)as the cause of the patient's resting angina.7

loji Klinigi, Ankara, 06100, Turkey. Tel.: +90 505 383 67 73.

r B.V. All rights reserved.

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[(Fig._1)TD$FIG]

Fig. 1 – The 12 lead ECG taken emergency department showing ST-T wave changes suggesting acute coronary syndrome.

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2. Case report

A 33-year-old man presented with substernal, crushing chestpain that lasted intermittenly for 60 min. He had none of theclassical risk factors for coronary artery disease, and didnot usealcohol, tobacco, or cocaine. He had a history of emergencycoronaryangiogramonemonthbeforedue tosimilar chestpain.An electrocardiogram (ECG) revealed sinus rhythm, biphasic Twaveswith preserved Rwaves inV1–V4 precordial leads (Fig. 1);but these appearances were similar to those noted before hisrecent discharge from the hospital (Fig. 2).We decided to followthe patient. However, in the early morning hours about 5.5 hafter admission, his severe chest pain restarted, and hisECG showed lamda-like diffuse ST segment elevation with

[(Fig._2)TD$FIG]

Fig. 2 – The 12 lead ECG taken one month

reciprocal ST depression in aVR and V1 (Fig. 3). Immediatelyafter starting intravenous nitroglycerine, his diffuse 'actionpotential-like' STsegmentelevationreturned tobaseline (Fig.4),concomitant with his pain subsiding. Sincewe did not have theprevious angiogram data; we planned to perform immediatecoronary angiography, which showed normal coronary arteriesexcept mild lesion at mid left anterior descending coronaryartery. The next day, his previous coronary angiogram takenonemonth earlier revealed that the angiographic findingsweresimilar to those noted before his recent discharge from theoutside hospital. The clinical and ECG pictures pointed to thediagnosis of a vasospastic-type Printzmetal angina, and thepatient responded well to calcium blockers and long-termnitroglycerin therapy and remained symptom-free throughouta 6-month follow-up.

before showing ST-T wave changes.

[(Fig._3)TD$FIG]

Fig. 3 – The 12 lead ECG during severe chest pain shows the diffuse ST segment elevation resembling the Greek letter lambda,called also 'action potential-like' shape or ‘‘tomb shape-like’’ in precordial leads.

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3. Discussion

Coronary artery spasm is a hyper-contraction of coronarysmooth muscle triggered by an increase of intracellularCa2+ in the presence of an increased Ca2+ sensitivity.8

[(Fig._4)TD$FIG]

Fig. 4 – The 12 lead ECG immediately after starting intravenous nreturned to baseline.

Electrocardiographically, the attacks of coronary spasm areassociatedwith either ST segment elevation or depression, ornegative U wave on ECG.8 Whereas the Wellens' syndrome ischaracterized by symmetrically inverted T-waves withpreserved R waves in the precordial leads suggestive ofimpending myocardial infarction due to a critical proximal

itroglycerine showing the his diffuse ST segment elevation

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left anterior descending stenosis,9 the pseudo-Wellens'syndrome caused by coronary artery spasm has also beenrarely reported in literature.10–13 These T-wave changesrepresent stunning and reperfusion of the myocardium.10–13 Complete or near-complete occlusion of LAD causes severemyocardial ischemia and angina. When coronary flow isrestored, reperfusion injury related repolarization abnormal-ities will be seen in precordial leads with inverted or biphasicT-waves. Absolute recovering of stunnedmyocardium resultsin normalized T-waves. Not only severe stenosis, any cause ofcoronary flow interruption, including spasm, could causecharacteristic T-wave changes.13 Our patient had a pseudo-Wellens sign on ECG at first admission, and a diffuse STsegment elevation on electrocardiogram resembling theGreek letter lambda, called also 'action potential-like' shapeor ‘‘tomb shape-like’’ in precordial leads (Fig. 3).14–16 Thisspecific ST segment elevation was accompanied by an up-sloping ST segment depression in aVR and V 1. ACS patientswithout culprit lesion and proof of coronary spasm have anexcellent prognosis in terms of survival and coronary eventsafter 3 years compared with patients with obstructive ACS;however, persistent angina represents a challenging problemin these patients, leading in some cases to repeated coronaryangiography.5

Conflicts of interest

The authors have none to declare.

r e f e r e n c e s

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13. Langston W, Pollack M. Pseudo-Wellens syndrome in acocaine user. Am J Emerg Med. 2006;24:122–123.

14. Riera AR, Ferreira C, Schapachnik E, Sanches PC, Moffa PJ.Brugada syndrome with atypical ECG: downsloping ST-segment elevation in inferior leads. J Electrocardiol.2004;37:101–104.

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`Action potential-like' ST elevation following pseudo-Wellens' electrocardiogram1 Introduction2 Case report3 DiscussionConflicts of interestReferences