T-wave inversions in inferior ST-elevation myocardial infarction - A case of “inferior Wellens sign”

• Published in: The American journal of emergency medicine Vol. 44; pp. 478.e1 - 478.e4
• Main Authors: Piña-Paz, Sylvia Alejandra, Singh, Amandeep
• Format: Journal Article
• Language: English
• Published: Philadelphia Elsevier Inc 01.06.2021; Elsevier Limited
• Subjects: Acute coronary syndromes; Asymptomatic; Cardiovascular disease; Case reports; Chest; Coronary artery; Coronary vessels; Electrocardiogram; Electrocardiography; Emergency medical care; Heart attacks; Inferior myocardial infarction; Inferior Wellen's; Ischemia; Myocardial infarction; Pain; Patients; Reperfusion; Stenosis; T-wave inversion; Waves; Wellen's syndrome; Inferior myocardial infarction; Inferior Wellen's; Wellen's syndrome; T-wave inversion; Electrocardiogram
• ISSN: 0735-6757; 1532-8171
• DOI: 10.1016/j.ajem.2020.10.053

Although T-wave inversions are nonspecific, in the appropriate clinical setting, the pattern of negative biphasic T-waves or T-wave inversion in V2-V3 can indicate critical stenosis of the left anterior descending coronary artery (i.e. “anterior Wellens sign”). Recently tall T-waves in V2-V3 have been reported in association with posterior reperfusion (i.e.“posterior Wellens sign”). Less commonly, negative biphasic T-waves or T-wave inversions in the inferior leads have been reported in association with critical stenosis of the right coronary artery (RCA) or left circumflex artery (LCx). We present a case where T wave inversions (i.e. “inferior Wellens sign”) and a tall T-wave in V2-V3 (i.e. “posterior Wellens sign”) preceded the development of an inferior-posterior ST-elevation myocardial infarction (STEMI). A 37-year-old man presented to the Emergency Department for one day of chest pain. On arrival, his pain had resolved, and his 1st ECG showed inverted/biphasic T-waves in lead III and aVF and a tall T wave in V2-V3. Three- and one-half hours after arrival, his chest pain returned and his ECG showed an inferior-posterior STEMI. New, focal T-wave inversions in an anatomic distribution may be an early warning sign of impending myocardial infarction. Careful attention to the T-waves during asymptomatic periods may assist in identifying patients that may have critical stenosis of an underlying coronary artery. In this case, T-wave inversions in the inferior leads, along with a tall T-wave in V2-V3, were seen prior to the development of an inferior-posterior STEMI.