Case summary:

An ALS crew responded to a 50s man who called 911 due to high blood pressure.  When the crew arrived, the patient reported he was concerned after checking his blood pressure and finding that it was “160/114.”  When the crew asked why he checked his BP, the patient said it was due to him having chest pain.  The following vitals and EKG were obtained.

Vitals: BP 134/76  HR 82,  RR 14,  Sat 97% on 15L

The patient reported that the chest pain came on suddenly about an hour prior and was very severe.  He reports it feels similar to when he had a heart attack a few years back and stents were placed.  The crew gave full dose aspirin and treated his pain with a dose of sublingual nitroglycerin.  The patient arrived at the receiving facility in stable condition. 

 Highlights of the case:

The EKG the crew obtained shows Wellens Waves.

The care that this crew provided was very good and was completely in line with our regional protocol.  While this patient did not have a STEMI pattern on EKG, this EKG shows Wellens waves.  In the setting of active chest pain, Wellens waves is consistent with an occlusive MI and should be treated the same as a STEMI.  Wellens waves are specific abnormalities in the T waves of V2 and V3.  There are two morphologies of Wellens waves.  The first is biphasic T waves with initial positivity and terminal negatively.  That is what is seen in the EKG above.  The other is deeply and symmetrically inverted T waves in V2 and V3 (shown below).

Wellens waves indicate a critical stenosis of the left anterior descending artery (LAD), which supplies the majority of the left ventricle with blood.  A blockage involving this vessel can cause a massive MI that can induce cardiogenic shock and sudden death.  In patients with active chest pain and these EKG changes, it is often considered a STEMI equivalent, and the patient is often taken for emergent percutaneous coronary intervention (PCI).  More importantly, patients often have transient chest pain from this blockage and are often pain free at the time that these EKG changes are seen.  Patients might refuse transport due to being pain free and then go on to have a massive MI or die suddenly in the next day.  If you ever see these changes on a 12-lead and the patient is trying to refuse, we should explain that they are at risk of having a massive heart attack and even dying if they are not immediately evaluated in the hospital.  Noticing this abnormality and convincing a patient to seek care can absolutely save his/her life.  In the case of this patient, the crew treated the patient per our protocol since Wellens waves are not indications for STEMI activation per our protocol.  However, if you see these changes in a patient with active chest pain, consider discussing cath lab activation with the receiving facility since that is most likely what this patient ultimately needs.