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Eur Heart J Case Rep
Eur Heart J Case Rep
ehjcr
European Heart Journal. Case Reports
2514-2119
Oxford University Press UK

10.1093/ehjcr/ytae460
ytae460
Cardiovascular Flashlight
AcademicSubjects/MED00200
Eurheartj/1
Eurheartj/2
Eurheartj/7
Eurheartj/15
Eurheartj/17
Extreme QT interval prolongation in Wellens syndrome
Abdelmaaboud Mostafa Department of Cardiology, Morriston Regional Cardiac Centre, Morriston Hospital, Heol Maes Eglwys, Swansea SA6 6NL, UK

https://orcid.org/0000-0002-8046-2939
Margulescu Andrei D Department of Cardiology, Morriston Regional Cardiac Centre, Morriston Hospital, Heol Maes Eglwys, Swansea SA6 6NL, UK

Gajendragadkar Parag Ravindra Handling Editor
Corresponding author. Tel: +44 (0) 1792530613, Email: andrei.margulescu@wales.nhs.uk
Conflict of interest: None declared.

9 2024
28 8 2024
28 8 2024
8 9 ytae46006 6 2024
05 8 2024
20 8 2024
10 9 2024
© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.
2024
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A 77-year-old man, with moderate aortic stenosis, was admitted with an 8 h history of typical chest pain and dyspnoea. Electrocardiogram (ECG) on admission (Panel A) showed non-specific intraventricular conduction delay, mild T-wave inversion in precordial leads, and normal QTc interval. Subsequently, the patient developed deep T-wave inversion across precordial leads and extreme QTc interval prolongation (maximal QTc, 708 ms at 33 h after symptom onset, at the time of revascularization, Panels B and C), which resolved by Day 6 at discharge (QTc 464 ms, Panel C).

Peak cardiac TnT level was 1958 ng/mL (normal, <14 ng/mL). Electrolyte levels were normal. Transthoracic echocardiogram on Day 1 revealed left ventricular ejection fraction of 40% (normal range, 55–65%) with akinesia in the left anterior descending artery (LAD) territory (see Supplementary material online, Video S1).

Anterior non-ST elevation myocardial infarction (NSTEMI) with Wellens ECG pattern was diagnosed. Coronary angiogram confirmed tight proximal LAD stenosis and further disease in mid-LAD segment (Panel D, white square). The proximal LAD lesion was treated successfully with drug-eluting stents (Panel D, black inset). Cardiac function normalized at 2 months follow-up (see Supplementary material online, Video S2).

Marked QTc interval prolongation in NSTEMI is presumed to be rare but is associated with increased risk of cardiac arrest. Since Wellens syndrome shares similar characteristics with takotsubo cardiomyopathy—where QTc interval prolongation is common—it is possible that QTc prolongation is under-recognized in patients with NSTEMI and Wellens ECG pattern, such as our case. In these patients, QTc-prolonging drugs should be avoided (including Singh–Vaughan Williams class Ia, Ic, and III antiarrhythmics), and electrolyte abnormalities should be corrected. Bradycardia should be treated, best using externalized atrial (AAI) pacemakers (in the absence of atrio-ventricular block), in order to avoid ventricular pacing that may be proarrhythmic. If torsades des pointes/ventricular fibrillation develops, beta-blockers (in the absence of uncorrected bradycardia) and/or intravenous lignocaine, together with overdrive AAI pacing, are indicated. Permanent devices (such as implantable cardiac defibrillators) are not usually indicated. Coronary revascularization does not result in immediate resolution of QTc prolongation. Physicians should be vigilant on monitoring QTc interval in these patients and prevent early discharges.

QT prolongation in Wellens syndrome. (Panel A) Electrocardiogram on admission. (Panel B) Maximal QT interval prolongation, 33 h after symptom onset. (Panel C) QT interval plotted against time from symptom onset. (Panel D) Coronary angiogram revealing tight proximal left anterior descending artery stenosis (white square) that was successfully treated with drug-eluting stents (black inset).

Supplementary Material

ytae460_Supplementary_Data

Supplementary material

Supplementary material is available at European Heart Journal – Case Reports online.

 

Consent: Consent for publication was obtained from the patient, in line with the COPE best practice.

Funding: None declared.

Data availability

The authors confirm that the data supporting the findings of this study are available within the article and its supplementary materials.
