CASE REPORT

Atypical Presentation of
Acute Coronary Syndrome
and Importance of Wellen’s
Syndrome

Dian Puspita Sari

030.15.058
 Typical chest pain in ACS:
1. Pressure like left sided chest pain
2. Radiation to the left shoulder ACS can present with no or
3. Dyspnea
atypical symptoms. Which can
4. Nausea, vomiting
5. Diaphoresis
lead to delayed diagnosis
6. Lightheadedness

BACKGROUND

is abnormal T wave changes in

Wellen’s Syndrome
patients with suspected ACS
Case Report

• A 74 years old women

• With diabetes, hypertention, dyslipidemia, and hypotyroidism

• Presnted with 3 week history of intermittent throat pain.

• Denied any chest pain, dsypnea, lightheadedness, nausea/vomiting, or
stomach or back pain. And she also denied any known coronary artery disease.

• Home medication : metformin, vit B12, enalopril, atrovastatin and

levothroxine.
• Vital sign were stable.
• Phsycal result were negative, including cardiac and pulmonary exam.
• Note : the patient completely asymtomatic at the time of evaluation.
Electrocardiogram (EKG)
Initial troponin was 0,9 ng/ml, which
went up to 1,7 ng/ml 6 hour later.

The patient was treated with : aspirin,

clopidogrel, atrovastatin, carvedilol,
and heparin infusion for NSTEMI

The patient was admitted to the

coronary care unit.
Angiogram
Discussion

•ACS is common and potentially life-threatening condition.

•33 % of ACS may mislead clinicans with atypical presentation wich could be dyspnea
(49,3%), diaphoresis (26.2%), nausea/vomiting (24.3%) or presyncope/syncope (19.1%).

•Atypical symptoms tend to occur more commenly among those who are older, female,
diabetic, hypertensive and with prior heart failure.
•Craniofacial pain is the sole presenting symptom in 6% of patients with an ischemic
cardiac event

•Craniofacial pain is a reffered pain from the afferent vagal nerve of the heart to efferents
somatic nerve to the head and neck , and prevalent more in women.
•The throat is the most common site of craniofacial pain, and also prevalent more in
women.
•Other sites of reffered pain are the mandibula, temporomandibular joint, ears, and neck and
teeth
Wellen’s Syndrome

• T wave changes in wellens syndrome are

associated with widely scattered electrical and
mechanical activities in myocardium and
severe myocardial dysfunction.

• Pattern A: has biphasic T waves in V2-V3

(25%)
• Pattern B: symmetric and deeply inverted T
wave in chest leads (75%)
Criteria Wellens Syndroms

1. Presence of pattern A : has 69 % sensitivity, 89 %

specificy, 86 % possitive-predictive value for significant
LAD occlusion. And presence of pattern B
2. History of angina
3. Pain-free period
4. Little or no elevation of ST segment
5. No Q waves in chest leads
6. Normal or minimal elevation of cardiac enzymes
Differential diagnoses of
T wave inversions:
– Acute coronary syndrome (ACS)
– Pulmonary embolism
– Myocarditis
– Left ventricular hyperthrophy
– Juvenile T wave
– Wolf Parkinson – White syndrome
– Digoxin toxicity
Conclusion

– In conclusion, craniofacial pain can be the sole presentation

of ACS, of which throat pain is the most common symptom
The presence of Wellens’ sign in the EKG can be a crucial
clue in patients with atypical presentation of ACS.
– Medically treated LAD stenosis with Wellens’ syndrome
eventually requires coronary intervention to prevent re-
occlusion and extensive myocardial injury.
Reference

1. Kyaw K, Latt H, Aung SSM, dkk. Atypical presentation

of acute coronary syndrome and importance of wellens
syndrome. American journal of case reports, 2018; 19 :
202-199