A 52-year-old man presents to the emergency department with a 2-hour history of chest pain that has now completely resolved. His 12-lead ECG shows deeply symmetrical T-wave inversions in leads V2 and V3, with an isoelectric ST segment and preserved R-wave progression. Troponin is normal. The pattern marked **A** in the diagram is recognized. Which of the following is the most appropriate next step in management?

Question

Accepted Answer

C. Admit to coronary care unit and proceed to urgent coronary angiography with intent to revascularize. ## Why "Admit to coronary care unit and proceed to urgent coronary angiography with intent to revascularize" is right

The pattern marked **A** — Wellens syndrome — is a specific electrocardiographic pattern characterized by deeply symmetrical T-wave inversions (or biphasic T waves) in precordial leads V2–V3 with an isoelectric or minimally elevated ST segment, normal Q waves, and normal R-wave progression. This pattern signals a critical, hemodynamically significant stenosis of the proximal left anterior descending (LAD) coronary artery and predicts impending extensive anterior myocardial infarction if untreated. The resolution of chest pain does not indicate resolution of risk; rather, it reflects myocardial stunning with critical LAD subocclusion. Without intervention, approximately 75% of patients progress to extensive anterior wall MI within days to weeks. The correct management is immediate admission with continuous telemetry, dual antiplatelet therapy (aspirin + P2Y12 inhibitor), anticoagulation, and urgent coronary angiography (ideally within 24 hours) with percutaneous coronary intervention of the offending proximal LAD stenosis (Braunwald Heart Disease 12e, Ch 56).

## Why each distractor is wrong

- **Discharge with outpatient cardiology follow-up in 2 weeks**: Wellens syndrome represents an unstable, high-risk substrate. Discharging the patient invites catastrophic progression to MI and death. The pain-free presentation can falsely reassure both patient and clinician, but the ECG pattern mandates urgent intervention.
- **Perform a treadmill stress test to assess inducible ischemia**: Stress testing is absolutely contraindicated in Wellens syndrome. Provocative testing can precipitate complete LAD occlusion, acute MI, and sudden death in this critically stenosed vessel.
- **Administer intravenous magnesium and monitor electrolytes for hypokalemia**: While hypokalemia (marked **D**) can cause T-wave abnormalities, the clinical presentation and ECG morphology are pathognomonic for Wellens syndrome, not electrolyte disturbance. Electrolyte management alone will not prevent LAD occlusion.

**High-Yield:** Wellens syndrome = pain-free interval + V2–V3 T-wave inversion + isoelectric ST = urgent LAD angiography; stress testing is contraindicated and can be fatal.

[cite:Braunwald Heart Disease 12e, Ch 56]

Answer

A. Discharge with outpatient cardiology follow-up in 2 weeks

Answer

B. Perform a treadmill stress test to assess inducible ischemia

Answer

D. Administer intravenous magnesium and monitor electrolytes for hypokalemia

Explanation

Why "Admit to coronary care unit and proceed to urgent coronary angiography with intent to revascularize" is right

Why each distractor is wrong

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