Writing Well.

THE ULTIMATE HIGH.Michelle Johnston // smaccGOLD Creative Workshop

language &

sentencesediting

processcreative

process

THE RULES

Whatever and However

you like.

BUT…

WELLEN’S SYNDROME

Wellen’s Syndrome consists of two ECG patterns, one of which is isoelectric or minimally elevated (i.e.

less than 1mm) ST segments with a straight or convex morphology that leads into a negative (inverted)

T wave, usually commencing at an angle of between 60° and 90°, and secondly biphasic T waves. This

syndrome, because of these changes and because the main culprit is a critical proximal LAD stenosis is

not infrequently known as the LAD coronary T wave syndrome. This syndrome has only recently been

described. The first case series was by Wellens in 1982. He published his series in the American Heart

Journal. This ECG pattern is seen when the patients are pain-free. In fact, when the patient is

experiencing symptoms of angina, the ST segment – T wave abnormalities frequently normalize, or may

even develop into a pattern of ST segment elevation, plus there is, additionally, a significant number

who will have no cardiac biomarker rise, despite the severity of the LAD occlusion and the degree of

pain. Interestingly, there is an extensively long list of differential diagnoses, many of which are

constantly and repeatedly overlooked, leading to terrible outcomes in the Emergency Department if not

picked up as early as possible. These include past myocardial ischaemia, left ventricular hypertrophy,

pulmonary embolism, digoxin effect, acute intracerebral events and pericarditis. The most important

thing to know about Wellen’s Syndrome is that it is considered a pre-infarction lesion and it has a high

risk of progressing onto full anterior wall infarction within 2 to 3 weeks. The management, once

recognized, is to establish aggressive treatment strategies for coronary ischaemia. Because there is

little collateral circulation to the anterior myocardial wall, an exercise stress test should not be ordered.

The patient should be referred immediately to a cardiologist and definitive coronary imaging (an

angiogram) needs to be undertaken. Education should be also be undertaken so that this condition is

promptly recognized and patients’ lives can be saved.

In summary, you want to avoid missing this syndrome like the plague.

THE WHATEVER [CONTENT]

• Content – if you have a passion for it, so will your readers

• Simplify your point. And when you think you’ve simplified it as much as you can, simplify it further.

WORKSHEETS???

THE HOWEVER

(technique)

A magnetic headline

and a perfect first

sentence

WELLEN’S SYNDROME

Wellen’s Syndrome consists of two ECG patterns, one of which is isoelectric or minimally elevated (i.e. less than 1mm) ST segments with a straight or convex morphology that leads into a negative (inverted) T wave, usually commencing at an angle of between 60° and 90°, and secondly biphasic T waves.

Many years later, as he faced the firing squad, Colonel

Aureliano Buendía was to remember that distant afternoon

when his father took him to discover ice.

It was love at first sight. The first time Yossarian saw the

chaplain, he fell madly in love with him.

The man in black fled across the desert, and the gunslinger

followed.

“

”

“”

“”

BEWARE WELLENS’ SYNDROME;

THE WIDOWMAKER

There are but a few ECG patterns, which, if

missed, may result in the owner’s sudden

and unexpected death. Wellens’ Syndrome

is perhaps the most feared of these, as its

ECG features can be subtle, and the usual

diagnostic criteria for an acute coronary

syndrome do not apply.

GIVE YOUR SENTENCES POWER

This syndrome, because of these changes

and because the main culprit is a critical

proximal LAD stenosis is not infrequently

known as the LAD coronary T wave

syndrome.

The diagnostic ECG changes are found in

the mid precordial leads – V2-V3 - and

comprise either deep symmetrical T wave

inversion, or biphasic T waves.

THE LILT OF RHYTHMThis syndrome has only recently been described.

The first case series was by Wellens in 1982. He

published his series in the American Heart Journal.

This ECG pattern is seen when the patients are

pain-free. In fact, when the patient is experiencing

symptoms of angina, the ST segment – T wave

abnormalities frequently normalize, or may even

develop into a pattern of ST segment elevation,

plus there is, additionally, a significant number who

will have no cardiac biomarker rise, despite the

severity of the LAD occlusion and the degree of

pain.

There is a lovely road that runs from Ixopo to the hills. These hills are grass-covered and rolling, and they are lovely beyond any singing of it.

There was music from my neighbor’s house through the summer nights. In his blue gardens men and girls came and went like moths among the whisperings and the champagne and the stars.

Professor Hein Wellens described this syndrome

relatively recently, in 1982, with a case series of

similar presentations. In his paper (American Heart

Journal) the consistent ECG pattern and clinical

features were strongly correlated with a critical

proximal LAD stenosis, and the patients had a high

rate of progression on to anterior wall myocardial

infarction if not treated (thus the alternate name, LAD

coronary T wave syndrome). Since then the condition

has become well recognized, and has been further

clarified. The ECG changes can be dynamic. During

bouts of pain, the ECG T wave changes may

paradoxically normalize, or even progress to ST

elevation, further complicating the diagnosis

CONCISION

Interestingly, there is an extensively long

list of differential diagnoses, many of

which are constantly and repeatedly

overlooked, leading to terrible outcomes

in the Emergency Department if not

picked up as early as possible.

The differential diagnosis list for

the ECG findings of precordial T

wave changes is broad, and

includes past myocardial

ischaemia, left ventricular

hypertrophy, pulmonary

embolism, digoxin effect, acute

intracerebral events and

pericarditis.

SCENEThese include past myocardial ischaemia,

left ventricular hypertrophy, pulmonary

embolism, digoxin effect, acute intracerebral

events and pericarditis. The most important

thing to know about Wellen’s Syndrome is

that it is considered a pre-infarction lesion

and it has a high risk of progressing onto full

anterior wall infarction within 2 to 3 weeks.

THE PERIL OF THE PASSIVE VOICE

Because there is little collateral circulation to

the anterior myocardial wall, an exercise

stress test should not be ordered. The

patient should be referred immediately to a

cardiologist and definitive coronary imaging

(an angiogram) needs to be undertaken.

Education should also be undertaken so that

this condition can be promptly recognized

and patients’ lives can be saved.

Once the diagnosis is suspected, the

clinician should make a hasty referral to the

Cardiology team. Exercise Stress Testing is

contraindicated, as these patients have little

collateral circulation to the anterior

myocardial wall, and catastrophic collapse

may ensue. Instead, prompt and aggressive

treatment for an acute coronary syndrome

should be instituted, and definitive imaging

and revascularization sought.

THE MAGIC OF WORDS

“In summary, you want to avoid missing this syndrome like the plague.”

THUS, like a newly discovered and

deadly animal species from the

Amazon, the Wellenoid pattern has

only recently crept into our critical care

consciousness. It is dangerous, and

well camouflaged, and it takes a skilled

and knowledgeable practitioner to spot

it, in order to avoid its precipitous death

strike.