Wellens' Warning — LAD Stenosis Pattern

ECG Criteria for Critical Left Anterior Descending Artery Stenosis

T-Wave Pattern in V2–V3

Type A (Pattern 1) — Biphasic T waves in V2–V3 Initial positive deflection followed by terminal negativity (biphasic, terminally inverted). Less common (~25%).

Type B (Pattern 2) — Deep symmetric T-wave inversions in V2–V3 Deep (≥2 mm), symmetric T-wave inversions in V2–V3 (may extend to V1–V6). More common (~75%).

Neither pattern present No Wellens' T-wave pattern identified.

Supporting Criteria

Isoelectric or minimally elevated ST segment (<1 mm) in V2–V3 Wellens' pattern occurs in the absence of significant ST elevation.

Key

No pathological Q waves Absence of Q waves suggests no completed infarction.

Key

Normal precordial R-wave progression Preserved R waves — no loss of anterior forces.

Key

History of recent angina (chest pain within 24–48 h, now resolved) T-wave changes characteristically appear during the pain-free interval.

Key

Normal or slightly elevated troponin Troponin may be normal or only mildly elevated.

No LBBB or LVH LBBB or LVH repolarization changes would obscure Wellens' pattern.

Result

Wellens' Pattern Not present

Supporting Criteria Met 0 / 6

Clinical Assessment —

Select a T-wave pattern to begin assessment.

Reference

de Zwaan C et al. Characteristic electrocardiographic pattern indicating a critical stenosis high in left anterior descending coronary artery in patients admitted because of impending myocardial infarction. Am Heart J. 1982;103(4):730-736

Clinical Significance

Wellens' syndrome indicates critical proximal LAD stenosis (>90%) with a high risk of extensive anterior wall MI. The ECG changes are seen during pain-free intervals. Without intervention, 75% of patients develop anterior wall MI within days to weeks. Stress testing is contraindicated. Urgent cardiac catheterization is indicated.