Pseudo-Wellens Syndrome Due to Vasospasm in a Patient Without Known Risk Factors

Wellens syndrome is an electrocardiogram (ECG) pattern characterized by biphasic (type A) or deeply inverted (type B) T waves in anterior leads because of critical left anterior descending artery (LAD) stenosis. Pseudo-Wellens is an ECG mimic of Wellens syndrome in which LAD stenosis is absent.

A 65-year-old man presented with sudden-onset angina. ECG obtained while angina-free demonstrated a type B Wellens pattern; coronary angiography revealed nonobstructive coronary artery disease. Fifteen days later, he returned with recurrent angina and upright T waves. As the pain resolved, he developed a type A Wellens pattern. Coronary angiography revealed severe vasospasm in the proximal LAD.

Wellens syndrome is highly specific for critical LAD stenosis, whereas pseudo-Wellens most often occurs because of vasospasm. Both increase the risk of acute myocardial infarction, and differentiation is critical for appropriate management.

This case highlights the need for a high index of suspicion for coronary vasospasm when a Wellens pattern occurs in the absence of coronary artery disease.