What should you do?

A 54 y/o M with pmh of smoking and htn presents to the ED for evaluation of intermittent chest pain that has worsened over the last few days, occasionally occurring at rest.  Currently the patient is asymptomatic and has no complaints.  Please review the patient's EKG.  A troponin was drawn and is negative, all other labs are wnl.  The patient currently wants to go home.  

Is the patient's EKG suggestive of any particular condition or concern?  What should you do?

Answer:  Wellen's Syndrome - EKG pattern occurring during chest-pain free periods in unstable angina patients --> signifies critical, proximal LAD stenosis

- Strongly correlated with early large anterior MI --> poor prognosis

- Patients will typically c/o recent history of chest pain; little or no elevation of cardiac enzymes; no precordial Q waves or loss of R waves; symmetric, deep TWI or biphasic T waves in V2-V5 or V6 during pain free periods; minimal (<1mm), if any, ST elevations

- The warning T-wave changes of Wellens’ are not uncommon in patients with unstable angina.

- If the patient develops chest pain, T waves may transiently become positive (pseudonormalization), or ST changes may develop

- Dispo: Recommended Rx --> early invasive approach, either cardiac catheterization with angioplasty or coronary artery bypass surgery. (ie --> DONT SEND HOME)