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\begin{document}

\title{Mini-Wellen's EKG (minimal terminal T wave inversion in V2-V3) is highly
predictive of high grade left main or proximal left anterior artery
disease}



\author[1]{Mohammad Reza Movahed}%
\affil[1]{The University of Arizona College of Medicine Tucson}%


\vspace{-1em}



  
  \date{June 10, 2024}


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\selectlanguage{english}
\begin{abstract}
Classic Wellen's syndrome or by some authors described as inverted U
waves is consistent of biphasic terminal T waves inversion usually seen
in V2 and V3 leads highly predictive of high grade left main (LM) or
proximal left anterior ascending artery (LAD) disease. In this case, we
are reporting a case of minimal terminal T wave changes not large enough
to qualify as Wellen's EKG but similar to classic Wellen was associated
with high grade LM and LAD disease despite negative troponins.%
\end{abstract}%



\sloppy


\textbf{Title: Mini-Wellen's EKG (minimal terminal T wave inversion in
V2-V3) is highly predictive of high grade left main or proximal left
anterior artery disease}

\textbf{Short title:} Prognostic of minimal Wellen like EKG changes

Author: Mohammad Reza Movahed, MD, PhD, FACP, FCCP, FACC,
FSCAI\textsuperscript{1,2,3}

University of Arizona Tucson\textsuperscript{1} University of Arizona
Phoenix\textsuperscript{2} and CareMore Health Care of
Arizona\textsuperscript{,3}

Correspondent:

M Reza Movahed, MD, PhD, FACP, FACC, FSCAI, FCCP

Clinical Professor of Medicine, University of Arizona, Tucson

Clinical Professor of Medicine, University of Arizona, Phoenix

4821 North Stone AV.

Tucson, AZ 85704

Tel: 949 400 0091

Email: rmova@aol.com

Conflict of interest: None

Keywords: Acute coronary syndrome; Wellen EKG; Inverted U waves;
anterior myocardial infarction; proximal left anterior ascending artery;
acute myocardial infarction

\textbf{Abstract:}

Classic Wellen's syndrome or by some authors described as inverted U
waves is consistent of biphasic terminal T waves inversion usually seen
in V2 and V3 leads highly predictive of high grade left main (LM) or
proximal left anterior ascending artery (LAD) disease. In this case, we
are reporting a case of minimal terminal T wave changes not large enough
to qualify as Wellen's EKG but similar to classic Wellen was associated
with high grade LM and LAD disease despite negative troponins.

\textbf{Case presentation:}

The patient was a 57 year old male with a history of diabetes mellitus,
hypertension, and recent cholecystectomy presented to the emergency room
with diarrhea, upper abdominal pain, and lower chest pressure only when
he took a deep breath. His inspiratory chest pain was persistent during
his hospital admission. His high sensitive 5 serial troponin levels were
within normal limits. His EKG was unremarkable except for minimal
terminal T wave inversion in V2 and V3 (figure 1). The patient underwent
upper endoscopy and was found to have Barrett's esophagus. He was
started on proton inhibitor therapy and was discharged. A few days
later, he presented again to the emergency department with similar chest
pain but now more prominent in his lower chest area. EKG showed a
similar finding with minimal terminal T waves inversion in V2-V3 but his
troponin levels were significantly elevated at 322 with a raise to
822ng/L (Figure 2). He underwent coronary angiography showing 80\%
distal left main (LM) and 90\% proximal left anterior descending (LAD)
artery disease (Figure 3). His cardiac function was normal. He underwent
successful coronary bypass surgery.

\textbf{Discussion:}

Dr. Gerson et al. in 1979 described first time terminally inverted T
waves as inverted U waves syndrome consistent with proximal left
anterior descending artery disease (1) He initially reported this EKG
pattern during exercise (1). A year later, Gerson et al. again described
the same finding at rest consistent with LAD ischemia. (2) De Zwaan and
Wellen et al. two years after Dr. Gerson's last publication in 1982,
published the same EKG pattern (3-4) at high risk for anterior
myocardial infarction. This pattern has been now confirmed and
recognized by many authors as a warning sign of LM or proximal LAD
disease. (5-7)

Reviewing original EKGs by Dr. Gerson and Wellens, a terminally inverted
T wave is clearly illustrated. In our case, we are reporting the first
case of very subtle EKG changes in the setting of high-grade LM and LAD
disease. The EKG changes were so subtle that were described as normal.
There is only one another reported case describing mini-Wellen' EKG
similar to our case. (8) Another case describes initial mini-Wellen's
EKG followed by classic Wellen's EKG. (9) Recognition of this very
subtle minimal inverted terminal T wave changes described in this
manuscript as ``mini Wellen' EKG'' is important in order to prevent
missing serious high-risk coronary disease involving LM or proximal LAD
similar to definite Wellen's EKG. On the other hand, other causes of so
called ``Pseudo-Wellens syndrome'' needs in differential diagnosis such
as sepsis or pancreatitis. (10,11)

\textbf{References:}

1. Gerson, M.C., et al., \emph{Exercise-induced U-wave inversion as a
marker of stenosis of the left} 1.Gerson, M.C., et
al.,\emph{Exercise-induced U-wave inversion as a marker of stenosis of
the left anterior descending coronary artery.} Circulation,
1979.\textbf{60} (5): p. 1014-20.

2. Gerson, M.C. and P.L. McHenry, \emph{Resting U wave inversion as a
marker of stenosis of the left anterior descending coronary artery.} Am
J Med, 1980. \textbf{69} (4): p. 545-50.

3. de Zwaan C, B.F., Wellens HJ. , \emph{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.\textbf{103}
((4pt2)): p. 730-6.

4. de Zwaan, C., et al., \emph{Angiographic and clinical characteristics
of patients with unstable angina showing an ECG pattern indicating
critical narrowing of the proximal LAD coronary artery.} Am Heart J,
1989. \textbf{117} (3): p. 657-657.

5. Movahed MR. Wellens' syndrome or inverted U-waves? Clin Cardiol. 2008
Mar;31(3):133-4.

6. Kahn, E.C. and K.B. Keller, \emph{Wellens' syndrome in the emergency
department.} J Emerg Nurs, 1991. \textbf{17} (2): p. 80-5

7. Lee Y, Habibzadeh MR, Movahed MR. Wellens Syndrome or Inverted U
Waves: A Serious Clinical Condition Needing Immediate Attention
Regardless of Symptoms. Am J Med. 2021 Nov;134(11):1365-1367.

8. Kawji MM, Glancy DL. Painless Mini-Wellens Sign 5 Minutes After
Exercise in a Man With Previously Undiagnosed Total Occlusion of the
Left Anterior Descending and Right Coronary Arteries. Am J Cardiol. 2017
Dec 1;120(11):2110-2112.

9. Arisha MJ, Belcher A, Annie F, Mian MS. Wellens syndrome progressing
from a very subtle type a to a classic type B Wellens pattern.
Cardiovasc Revasc Med. 2023 May 23:S1553-8389(23)00199-9.

10. Ju TR, Yeo I, Pontone G, Bhatt R. Pseudo-Wellens syndrome from
sepsis-induced cardiomyopathy: a case report and review of the
literature. J Med Case Rep. 2021 Apr 6;15(1):151

11. Effoe VS, O'Neal W, Santos R, Rubinsztain L, Zafari AM.
Pseudo-Wellens syndrome, acute pancreatitis, and an anomalous coronary
artery: a case report. J Med Case Rep. 2019 Dec 30;13(1):387

Figure 1: Arrows are showing mini Wellen's EKG seen during first
admission\selectlanguage{english}
\begin{figure}[H]
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\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

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Figure 2: Arrows are showing mini Wellen's EKG seen during second
admission\selectlanguage{english}
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\includegraphics[width=0.70\columnwidth]{figures/image2/image2}

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Figure 3: Coronary angiogram showing high grades left main and prox left
anterior descending artery disease\selectlanguage{english}
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\includegraphics[width=0.70\columnwidth]{figures/image3/image3}

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