ST-Elevation Myocardial Infarction after Pharmacologic Persantine Stress Test in a Patient with Wellens’ Syndrome

Wellens’ syndrome, also known as LAD coronary T-wave inversion syndrome, is a characteristic ECG pattern that highly suggests critical stenosis of the proximal left anterior descending (LAD) coronary artery. 75% of patients with this finding go on to develop acute anterior wall myocardial infarction within one week unless prevented by early intervention on the culprit lesion. Most instances of ST-elevation occurring during cardiac stress testing have been observed with exercise, with only seven cases reported in the literature with pharmacologic stress. We present a case of a patient with no known cardiac disease who presented with chest pain and an ECG consistent with Wellens’ syndrome that developed an acute anterior wall ST-elevation myocardial infarction after pharmacologic stress test. 1. Introduction Wellens’ syndrome typically presents with the characteristic ECG findings of biphasic T-waves or deep symmetrical T-wave inversions in the precordial leads (leads V1–V4). This ECG finding usually occurs during a pain-free period and is highly suggestive of critical proximal LAD coronary artery stenosis. Given the significant number of patients that will go on to develop acute anterior wall myocardial infarctions, it is critical that all physicians recognize this classic ECG pattern and institute measures for the patient to undergo urgent coronary angiography and revascularization. If left untreated, managed medically, or further risk-stratified by cardiac stress testing, the patient may develop an extensive myocardial infarction or sudden death. 2. Case Presentation A 72-year-old Hispanic male with a past medical history of hypertension, hyperlipidemia, end-stage kidney disease on hemodialysis, and cerebrovascular accident 5 years before presented to the emergency department with midsternal crushing chest pain that awoke him up from sleep at 7？am in the morning. The pain radiated to his jaws bilaterally and was associated with diaphoresis. The pain continued for 30 minutes until EMS arrived and improved after sublingual nitroglycerin and chewable aspirin 325？mg. Significant social history included a history of cigarette smoking. No additional pertinent history was appreciated including review of systems, family history, and social history. The patient’s blood pressure on presentation was 137/70？mmHg, heart rate was 102？bpm, and physical exam was documented as essentially within normal limits. The patient’s electrocardiogram upon presentation (Figure 1) showed a sinus tachycardia at a rate of 102 beats per minute, LVH with QRS widening, and prolonged