BACKGROUND: Acute chest pain is a common presentation in emergency departments worldwide. Ruling out acute coronary syndrome is essential in ensuring patient safety. Workup includes electrocardiogram (ECG) and cardiac biomarkers. Wellens syndrome is characterized by a history of chest pain, normal or minimally elevated biomarkers, no STEMI/Q-waves, and specific ECG changes. These changes consist of biphasic T waves in lead V2 and V3 or deep symmetrically inverted T waves in leads V1–V4.

CASE REPORT: A 55-year-old male presented to the emergency department with acute chest pain in a background of active smoking, hypertension, and hyperlipidemia. His ECG was characteristic of Wellens syndrome type 1 and negative cardiac biomarkers. His TIMI (thrombolysis in myocardial infarction) score was 2, however, he failed conservative management necessitating urgent coronary angiogram. Critical stenosis of the proximal left anterior descending (LAD) coronary artery was found which required 2 drug eluting stents. He was discharged home asymptomatic on optimal medical therapy.

CONCLUSIONS: Conventional management of patients with NSTEMI (non-ST-elevation myocardial infarction) and unstable angina with risk stratification utilizing TIMI score may not be appropriate in patient with Wellens syndrome. This highlights the importance of ECG recognition and urgent percutaneous intervention in patients with Wellens syndrome. Failure to identify this clinical syndrome could result in significant morbidity and mortality because it relates to critical stenosis and imminent large myocardial infarction.

Keywords: acute coronary syndrome, Electrocardiography, percutaneous coronary intervention, Chest Pain, Coronary Stenosis, Hyperlipidemias, Hypertension, smokers, Syndrome