Title : A complex case of wellens syndrome in an elderly patient with multimorbidity: Diagnostic challenges and management of NSTEMI and comorbid conditions
Abstract:
Wellens syndrome is a critical electrocardiographic finding that suggests significant stenosis of the left anterior descending artery (LAD), often preceding a large anterior wall myocardial infarction. This clinical vignette describes an 83-year-old male with a complex medical history including hypertension, paroxysmal atrial fibrillation, generalized myasthenia gravis, heart failure with preserved ejection fraction (HFpEF), nephrolithiasis, and a history of prostate cancer. He presented with two weeks of intermittent chest pain, which progressed to rest pain, and was initially diagnosed with a hypertensive emergency and non-ST elevation myocardial infarction (NSTEMI). On admission, his blood pressure was severely elevated, with systolic readings in the 200s, and troponins were found to be elevated, supporting the diagnosis of NSTEMI.
Initial electrocardiograms (ECGs) did not show clear ischemic changes, but evolving deep, symmetric T-wave inversions in the precordial leads on subsequent ECGs were indicative of Wellens syndrome. These changes strongly suggested severe stenosis in the LAD, and the patient underwent coronary angiography which revealed significant two-vessel coronary artery disease (CAD), with 90% and 80% stenosis in the mid-to-distal LAD. The patient subsequently underwent percutaneous coronary intervention (PCI) with placement of overlapping drug-eluting stents (DES) in the LAD, successfully restoring blood flow.
The patient's clinical course was complicated by acute anemia, thought to be multifactorial, including a urinary bleed from nephrolithiasis, gastrointestinal losses, and iatrogenic causes related to anticoagulation therapy. His anemia was managed with intravenous iron, and his blood pressure and heart failure symptoms were stabilized with appropriate medications, including metoprolol and furosemide. His anticoagulation regimen was adjusted due to anemia and a plan for follow-up angiography of the right coronary artery (RCA) was made. Neurology was consulted regarding the potential interaction of statins with myasthenia gravis, and alternative lipid-lowering strategies were considered.
This case highlights the importance of recognizing Wellens syndrome as an early indicator of critical LAD stenosis, even in the absence of initial ischemic ST changes. It also emphasizes the complexity of managing patients with multiple comorbidities, including cardiovascular disease, neurological disorders, and hematologic abnormalities, where careful coordination between specialties is essential. The patient was discharged with ongoing management of his cardiovascular conditions, planned follow-up for anemia and anticoagulation therapy, and close monitoring of his myasthenia gravis and heart failure symptoms. The case underscores the need for vigilance in elderly patients with multifactorial health concerns, especially when presenting with atypical symptoms such as chest pain in the setting of poorly controlled hypertension.
