We report the case of a woman in her 70s presenting to the emergency department with syncope, troponemia, and an electrocardiogram with deep symmetric T-wave inversions in V2 and V3 and prolonged QTc. Her presentation was concerning for acute coronary syndrome, Wellens syndrome in particular, given the elevated troponin levels, lack of ST segment changes, and characteristic T-wave findings. The diagnosis was confirmed with angiography that showed a critical left anterior descending (LAD) artery occlusion. Since myocardial infarction does not typically present with syncope, we explored the differential diagnoses for T-wave inversions, which include electrolyte abnormalities, medications, intracranial hemorrhage, pulmonary embolism, and other cardiac diseases that were ruled out in our patient. We also explored the pathophysiology leading to syncope in the setting of acute myocardial infarction including arrhythmias and exaggerated neurally mediated response. Our patient received two drug-eluting stents to the LAD artery and was started on dual antiplatelet therapy, beta-blockers, and an angiotensin-converting enzyme inhibitor.

Keywords:
Electrocardiogram, Acute coronary syndromes, Acute myocardial infarction, Syncope
1.
de Zwaan C, Bar FW, Wellens HJ: Characteristic electrocardiographic pattern indicating a critical stenosis high in left anterior descending coronary artery in patients admitted because of impending myocardial infarction. Am Heart J 1982;103:730-736.
2.
de Zwaan C, Bar FW, Janssen JH, et al: Angiographic and clinical characteristics of patients with unstable angina showing an ECG pattern indicating critical narrowing of the proximal LAD coronary artery. Am Heart J 1989;117:657-665.
3.
Tandy TK, Bottomy DP, Lewis JG. Wellens' syndrome. Ann Emerg Med 1999;33:347-351.
4.
Wilson MG, Sharma S, Carre F, et al: Significance of deep T-wave inversions in asymptomatic athletes with normal cardiovascular examinations: practical solutions for managing the diagnostic conundrum. Br J Sports Med 2012;46(suppl 1):i51-i58.
5.
Hayden GE, Brady WJ, Perron AD, Somers MP, Mattu A: Electrocardiographic T-wave inversion: differential diagnosis in the chest pain patient. Am J Emerg Med 2002;20:252-262.
6.
Manocha KK, Snipelisky D, Anavekar NS: Intracranial hemorrhage and deep T-wave inversions. JAMA Int Med 2015;175:1223-1225.
7.
Puppala VK, Dickinson O, Benditt DG: Syncope: classification and risk stratification. J Cardiol 2014;63:171-177.
8.
Abuin G, Nieponice A, Barcelo A, Rojas-Granados A, Leu PH, Arteaga-Martinez M: Anatomical reasons for the discrepancies in atrioventricular block after inferior myocardial infarction with and without right ventricular involvement. Tex Heart Inst J 2009;36:8-11.
9.
Shepherd JT: The heart as a sensory organ. J Am Coll Cardiol 1985;5:83B-87B.
10.
Longhurst JC, Tjen-A-Looi SC, Fu LW: Cardiac sympathetic afferent activation provoked by myocardial ischemia and reperfusion: mechanisms and reflexes. Ann NY Acad Sci 2001;940:74-95.
11.
Zucker IH: Left ventricular receptors: physiological controllers or pathological curiosities? Basic Res Cardiol 1986;81:539-557.
12.
Emery RW, Estrin JA, Wahler GM, Booth AM, Swayze CR, Fox IJ: Reflex hypotension due to regional activation of left ventricular mechanoreceptors to explain the hypotension noted in clinical myocardial ischaemia or reperfusion. Cardiovasc Res 1986;20:161-170.
© 2016 S. Karger AG, Basel
2016
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.