Cardiol Res

Cardiology Research, ISSN 1923-2829 print, 1923-2837 online, Open Access

Article copyright, the authors; Journal compilation copyright, Cardiol Res and Elmer Press Inc

Journal website http://www.cardiologyres.org

Original Article

Volume 10, Number 3, June 2019, pages 135-141

Prevalence and Clinical Implication of Wellens’ Sign in Patients With Non-ST-Segment Elevation Myocardial Infarction

Figure 1. Electrocardiograms with symmetrically inverted T waves (≥ 0.10 mV) (Fig. 1a) and biphasic T waves in both leads V2 and V3 (Fig. 1b).

**Table 1.** Demographic, Hemodynamic, and Laboratory Characteristics of Patients With and Without Wellens’ Sign
	Wellens’ sign (n = 24)	Control (n = 250)	P value
Data are expressed as a number (percent) or median (interquartile range). eGFR: estimated glomerular filtration rate.
Demographics
Age (years)	68 (58 - 79)	64 (55 - 72)	0.24
Female	15 (62.5)	97 (38.8)	0.024
Body mass index (kg/m²)	26.3 (24.6 - 28.9)	27.5 (24.1 - 30.8)	0.24
Hypertension	15 (62.5)	177 (70.8)	0.4
Diabetes mellitus	6 (25.0)	82 (32.8)	0.43
Hyperlipidemia	10 (41.7)	141 (56.4)	0.17
Chronic kidney disease	7 (29.2)	59 (23.6)	0.54
History of coronary artery disease	6 (25.0)	50 (20.0)	0.56
Family history of coronary artery disease	3 (12.5)	61 (24.4)	0.31
Current smoker	4 (16.7)	68 (27.2)	0.26
Previous myocardial infarction	1 (4.2)	31 (12.4)	0.33
Thrombolysis in myocardial infarction risk score
Low risk (0 - 2)	8 (33.3)	54 (21.6)	0.47
Intermediate risk (3 - 4)	12 (50.0)	147 (58.8)	0.47
High risk (5 - 7)	4 (16.7)	49 (19.6)	0.47
Symptom, presence of chest pain at emergency room	19 (79.2)	219 (87.6)	0.22
Hemodynamic and laboratory data
Systolic blood pressure (mm Hg)	141 (122 - 159)	140 (123 - 156)	0.78
Diastolic blood pressure (mm Hg)	76 (73 - 98)	80 (72 - 91)	0.77
Heart rate (beat/min)	82 (64 - 88)	75 (66 - 89)	0.85
Hemoglobin (g/L)	13.0 (12.1 - 14.3)	13.5 (12.2 - 14.5)	0.45
White blood cell count (10⁹/L)	8.2 (6.9 - 11.0)	8.5 (6.7 - 10.3)	0.83
eGFR (mL/min/1.73 m²)	69 (54 - 88)	80 (61 - 93)	0.19
Elevated first troponin	22 (91.7)	212 (84.8)	0.54
Peak troponin I (µg/L)	0.67 (0.11 - 4.36)	0.94 (0.14 - 6.45)	0.33
Killip class on admission
Killip class I on admission	21 (87.5)	229 (91.6)	0.094
Killip class II on admission	1 (4.2)	18 (7.2)	0.094
Killip class III on admission	1 (4.2)	2 (0.8)	0.094
Killip class IV on admission	1 (4.2)	1 (0.4)	0.094
Left ventricular ejection fraction (%)	53 (45 - 60)	60 (55 - 65)	0.013

Table 1. Demographic, Hemodynamic, and Laboratory Characteristics of Patients With and Without Wellens’ Sign

Wellens’ sign (n = 24)

Control (n = 250)

P value

Data are expressed as a number (percent) or median (interquartile range). eGFR: estimated glomerular filtration rate.

Demographics

Age (years)

68 (58 - 79)

64 (55 - 72)

0.24

Female

15 (62.5)

97 (38.8)

0.024

Body mass index (kg/m²)

26.3 (24.6 - 28.9)

27.5 (24.1 - 30.8)

0.24

Hypertension

15 (62.5)

177 (70.8)

0.4

Diabetes mellitus

6 (25.0)

82 (32.8)

0.43

Hyperlipidemia

10 (41.7)

141 (56.4)

0.17

Chronic kidney disease

7 (29.2)

59 (23.6)

0.54

History of coronary artery disease

6 (25.0)

50 (20.0)

0.56

Family history of coronary artery disease

3 (12.5)

61 (24.4)

0.31

Current smoker

4 (16.7)

68 (27.2)

0.26

Previous myocardial infarction

1 (4.2)

31 (12.4)

0.33

Thrombolysis in myocardial infarction risk score

Low risk (0 - 2)

8 (33.3)

54 (21.6)

0.47

Intermediate risk (3 - 4)

12 (50.0)

147 (58.8)

0.47

High risk (5 - 7)

4 (16.7)

49 (19.6)

0.47

Symptom, presence of chest pain at emergency room

19 (79.2)

219 (87.6)

0.22

Hemodynamic and laboratory data

Systolic blood pressure (mm Hg)

141 (122 - 159)

140 (123 - 156)

0.78

Diastolic blood pressure (mm Hg)

76 (73 - 98)

80 (72 - 91)

0.77

Heart rate (beat/min)

82 (64 - 88)

75 (66 - 89)

0.85

Hemoglobin (g/L)

13.0 (12.1 - 14.3)

13.5 (12.2 - 14.5)

0.45

White blood cell count (10⁹/L)

8.2 (6.9 - 11.0)

8.5 (6.7 - 10.3)

0.83

eGFR (mL/min/1.73 m²)

69 (54 - 88)

80 (61 - 93)

0.19

Elevated first troponin

22 (91.7)

212 (84.8)

0.54

Peak troponin I (µg/L)

0.67 (0.11 - 4.36)

0.94 (0.14 - 6.45)

0.33

Killip class on admission

Killip class I on admission

21 (87.5)

229 (91.6)

0.094

Killip class II on admission

1 (4.2)

18 (7.2)

0.094

Killip class III on admission

1 (4.2)

2 (0.8)

0.094

Killip class IV on admission

1 (4.2)

1 (0.4)

0.094

Left ventricular ejection fraction (%)

53 (45 - 60)

60 (55 - 65)

0.013

**Table 2.** Electrocardiographic Characteristics of Patients With and Without Wellens’ Sign
	Wellens’ sign (n = 24)	Control (n = 250)	P value
Data are expressed as a number (percent) or median (interquartile range).
Heart rate (beat/min)	81 (73 - 95)	79 (71 - 92)	0.74
Atrial fibrillation	2 (8.3)	7 (2.8)	0.18
Biphasic T wave at leads V2 and V3	10 (41.7)	0 (0.0)	< 0.001
Symmetrically inverted T wave (≥ 0.10 mV) in leads V2 and V3	14 (58.3)	0 (0.0)	< 0.001
Symmetrically inverted T wave (≥ 0.20 mV) in leads V2 and V3	11 (45.8)	0 (0.0)	< 0.001
Symmetrically inverted T wave (≥ 0.30 mV) in leads V2 and V3	4 (16.7)	0 (0.0)	< 0.001
Biphasic or symmetrically inverted T wave (≥ 0.10 mV) in lead V1	14 (58.3)	71 (28.4)	0.002
Biphasic or symmetrically inverted T wave (≥ 0.10 mV) in lead V4	18 (75.0)	25 (10.0)	< 0.001
Biphasic or symmetrically inverted T wave (≥ 0.10 mV) in lead V5	12 (50.0)	30 (12.0)	< 0.001
Biphasic or symmetrically inverted T wave (≥ 0.10 mV) in lead V6	8 (33.3)	27 (10.8)	0.005
ST segment depression (≥ 0.05 mV)	1 (4.2)	81 (32.4)	0.004
Anterior ST depression (V1 - V4)	1 (4.2)	27 (10.8)	0.49
Lateral ST depression (I, aVL,V5, and V6)	1 (4.2)	67 (26.8)	0.014
Inferior ST depression (II, III, and aVF)	0 (0.0)	35 (14.0)	0.053

Table 2. Electrocardiographic Characteristics of Patients With and Without Wellens’ Sign

Wellens’ sign (n = 24)

Control (n = 250)

P value

Data are expressed as a number (percent) or median (interquartile range).

Heart rate (beat/min)

81 (73 - 95)

79 (71 - 92)

0.74

Atrial fibrillation

2 (8.3)

7 (2.8)

0.18

Biphasic T wave at leads V2 and V3

10 (41.7)

0 (0.0)

< 0.001

Symmetrically inverted T wave (≥ 0.10 mV) in leads V2 and V3

14 (58.3)

0 (0.0)

< 0.001

Symmetrically inverted T wave (≥ 0.20 mV) in leads V2 and V3

11 (45.8)

0 (0.0)

< 0.001

Symmetrically inverted T wave (≥ 0.30 mV) in leads V2 and V3

4 (16.7)

0 (0.0)

< 0.001

Biphasic or symmetrically inverted T wave (≥ 0.10 mV) in lead V1

14 (58.3)

71 (28.4)

0.002

Biphasic or symmetrically inverted T wave (≥ 0.10 mV) in lead V4

18 (75.0)

25 (10.0)

< 0.001

Biphasic or symmetrically inverted T wave (≥ 0.10 mV) in lead V5

12 (50.0)

30 (12.0)

< 0.001

Biphasic or symmetrically inverted T wave (≥ 0.10 mV) in lead V6

8 (33.3)

27 (10.8)

0.005

ST segment depression (≥ 0.05 mV)

1 (4.2)

81 (32.4)

0.004

Anterior ST depression (V1 - V4)

1 (4.2)

27 (10.8)

0.49

Lateral ST depression (I, aVL,V5, and V6)

1 (4.2)

67 (26.8)

0.014

Inferior ST depression (II, III, and aVF)

0 (0.0)

35 (14.0)

0.053

**Table 3.** Predictive Values of Wellens’ Sign, Either Symmetrically Inverted T Waves (≥ 0.10 mV) or Biphasic T Waves in Both Leads V2 and V3, for Left Anterior Descending Artery Culprit
	Sensitivity	Specificity	PPV	NPV	Accuracy
PPV: positive predictive value; NPV: negative predictive value.
Biphasic T wave in leads V2 and V3	12.30%	99.00%	80.00%	78.40%	78.50%
Symmetrically inverted T wave (≥ 0.10 mV) in leads V2 and V3	12.30%	97.10%	57.10%	78.10%	77.00%
Symmetrically inverted T wave (≥ 0.20 mV) in leads V2 and V3	9.20%	97.60%	54.50%	77.60%	76.70%
Symmetrically inverted T wave (≥ 0.30 mV) in leads V2 and V3	3.10%	99.00%	50%	76.70%	76.30%
Either biphasic or symmetrically inverted T wave (≥ 0.10 mV) in leads V2 and V3	24.60%	96.20%	66.70%	80.40%	79.20%

Table 3. Predictive Values of Wellens’ Sign, Either Symmetrically Inverted T Waves (≥ 0.10 mV) or Biphasic T Waves in Both Leads V2 and V3, for Left Anterior Descending Artery Culprit

Sensitivity

Specificity

PPV

NPV

Accuracy

PPV: positive predictive value; NPV: negative predictive value.

Biphasic T wave in leads V2 and V3

12.30%

99.00%

80.00%

78.40%

78.50%

Symmetrically inverted T wave (≥ 0.10 mV) in leads V2 and V3

12.30%

97.10%

57.10%

78.10%

77.00%

Symmetrically inverted T wave (≥ 0.20 mV) in leads V2 and V3

9.20%

97.60%

54.50%

77.60%

76.70%

Symmetrically inverted T wave (≥ 0.30 mV) in leads V2 and V3

3.10%

99.00%

50%

76.70%

76.30%

Either biphasic or symmetrically inverted T wave (≥ 0.10 mV) in leads V2 and V3

24.60%

96.20%

66.70%

80.40%

79.20%

**Table 4.** Angiographic Characteristics and In-Hospital Clinical Outcomes of Patients With and Without Wellens’ Sign
	Wellens’ sign (n = 24)	Control (n = 250)	P value
Data are expressed as a number (percent) or median (interquartile range).
Angiographic findings
Interval to angiography from presentation (day)	0.99 (0.31 - 1.63)	1.09 (0.60 - 1.95)	0.38
Early invasive strategy within 24 h	13 (54.2)	114 (45.6)	0.42
Non-obstructive coronary artery disease	6 (25.0)	54 (21.6)	0.7
Multi-vessel disease	7 (29.2)	122 (48.8)	0.066
Three-vessel disease	1 (4.2)	45 (18.0)	0.093
Left main disease	0 (0.0)	12 (4.8)	0.61
Left main and/or three-vessel disease	1 (4.2)	51 (20.4)	0.057
Left anterior descending artery disease (stenosis ≥ 70%)	16 (66.7)	130 (52.0)	0.17
Left anterior descending artery culprit	16 (66.7)	49 (19.6)	< 0.001
Proximal left anterior descending artery culprit	8 (33.3)	36 (14.4)	0.035
Mid left anterior descending artery culprit	8 (33.3)	13 (5.2)	< 0.001
Left circumflex artery disease (stenosis ≥ 70%)	5 (20.8)	109 (43.6)	0.031
Left circumflex artery culprit	2 (8.3)	58 (23.2)	0.093
Right coronary artery disease (stenosis ≥ 70%)	5 (20.8)	117 (46.8)	0.014
Right coronary artery culprit	0 (0.0)	65 (26.0)	0.004
Pre-procedural thrombolysis in myocardial infarction flow
0/1	1 (4.2)	50 (20.0)	0.058
2/3	23 (95.8)	200 (80.0)	0.058
In-hospital procedure
In-hospital percutaneous coronary intervention	16 (66.7)	159 (63.6)	0.77
In-hospital coronary artery bypass grafting	1 (4.2)	18 (7.2)	1
Intra-aortic balloon pump	1 (4.2)	4 (16)	0.37
Intubation	1 (4.2)	2 (0.8)	0.24
In-hospital outcomes
All-cause mortality	0 (0.0)	1 (0.4)	1
Recurrent myocardial infarction	0 (0.0)	1 (0.4)	1

Table 4. Angiographic Characteristics and In-Hospital Clinical Outcomes of Patients With and Without Wellens’ Sign

Wellens’ sign (n = 24)

Control (n = 250)

P value

Data are expressed as a number (percent) or median (interquartile range).

Angiographic findings

Interval to angiography from presentation (day)

0.99 (0.31 - 1.63)

1.09 (0.60 - 1.95)

0.38

Early invasive strategy within 24 h

13 (54.2)

114 (45.6)

0.42

Non-obstructive coronary artery disease

6 (25.0)

54 (21.6)

0.7

Multi-vessel disease

7 (29.2)

122 (48.8)

0.066

Three-vessel disease

1 (4.2)

45 (18.0)

0.093

Left main disease

0 (0.0)

12 (4.8)

0.61

Left main and/or three-vessel disease

1 (4.2)

51 (20.4)

0.057

Left anterior descending artery disease (stenosis ≥ 70%)

16 (66.7)

130 (52.0)

0.17

Left anterior descending artery culprit

16 (66.7)

49 (19.6)

< 0.001

Proximal left anterior descending artery culprit

8 (33.3)

36 (14.4)

0.035

Mid left anterior descending artery culprit

8 (33.3)

13 (5.2)

< 0.001

Left circumflex artery disease (stenosis ≥ 70%)

5 (20.8)

109 (43.6)

0.031

Left circumflex artery culprit

2 (8.3)

58 (23.2)

0.093

Right coronary artery disease (stenosis ≥ 70%)

5 (20.8)

117 (46.8)

0.014

Right coronary artery culprit

0 (0.0)

65 (26.0)

0.004

Pre-procedural thrombolysis in myocardial infarction flow

0/1

1 (4.2)

50 (20.0)

0.058

2/3

23 (95.8)

200 (80.0)

0.058

In-hospital procedure

In-hospital percutaneous coronary intervention

16 (66.7)

159 (63.6)

0.77

In-hospital coronary artery bypass grafting

1 (4.2)

18 (7.2)

Intra-aortic balloon pump

1 (4.2)

4 (16)

0.37

Intubation

1 (4.2)

2 (0.8)

0.24

In-hospital outcomes

All-cause mortality

0 (0.0)

1 (0.4)

Recurrent myocardial infarction

0 (0.0)

1 (0.4)