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Discussion
Wellens ’ syndrome is a clinical syndrome characterised
by biphasic or deeply inverted T waves in leads V2 and V3 , together with and a recent history of chest pain that has resolved . The syndrome is highly suggestive of anterior wall ischaemia , typically due to critical stenosis of the proximal LAD . The ECG pattern reflects a preinfarction state for massive anterior wall MI . 8
It is postulated that Wellens ’ syndrome occurs as a result of atherosclerotic plaque rupture , leading to transient LAD occlusion , with probable clot lysis before MI occurs . 8
There are two recognised Wellens ’ patterns . Type A describes biphasic T waves in leads
V2 and V3 ( see figure 1 ) and type B describes inverted T waves in leads V2 and V3 . The two often exist on a spectrum that transforms from type A to type B as disease progresses . 8
It is important to note that the ECG abnormalities may persist when patients are painfree . The T wave inversion has been reported to persist for hours to weeks . 8
Wellens ’ syndrome can easily be missed as patients often present pain-free , meaning the clinical suspicion for acute coronary syndrome is lower . Additionally , there may be only subtle ECG changes and little to no rise in cardiac enzymes . 8
Timely recognition of this ECG pattern is imperative not only for prompt identification and treatment of critical lesions , but also to avoid interventions with potentially fatal outcomes . Specifically , stress tests are contraindicated as they will cause an increased oxygen demand that may precipitate AMI , arrhythmia or sudden death . 8
This case serves as a compelling reminder to
consider cardiac pathology in women presenting with ‘ atypical ’ symptoms , in particular those with risk factors for cardiovascular disease .
A number of differences in MI symptomology between the sexes have been identified . Chest pain remains the most common symptom of MI in both women and men , however women are more likely to experience additional non-chest pain symptoms that can distract from the diagnosis . These include fatigue , weakness , breathlessness or dizziness . 1 , 2 Women are also more likely to experience additional non-chest pain , including intense upper abdominal pain , intense back pain , and indigestion . 3 These differences contribute to delayed diagnosis of MI in women compared with
Timely recognition of this ECG pattern is imperative not only for prompt identification and treatment of critical lesions , but also to avoid interventions with potentially fatal outcomes .
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their male counterparts . 1 , 2
Sex differences also influence the presentation
and prevalence of traditional cardiovascular disease risk factors in women and men . Some of the traditional risk factors have a greater impact in women than men . For example , type 2 diabetes mellitus , hypertension and smoking all confer a greater risk for MI in women than men . 4 Also worth considering are non-traditional risk factors that are unique to or more prevalent in women . These include pregnancy complications , including gestational diabetes , hypertensive disorders of pregnancy , having small-for-gestational age infants , and preterm delivery , in addition to early menopause and polycystic ovary syndrome . 5 , 6 , 7
Outcome
Xie undergoes a repeat echocardiogram two months after hospital discharge , which shows significant improvement , with all parameters returning to normal .
References on request from kate . kelso @ adg . com . au
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Figure 1 . ECG showing Type A Wellens ’ pattern with biphasic T waves in V2-V5 . Additionally , there is T wave inversion in leads I and aVL , LVH and J point elevation with upsloping ST segments from V2-V5 .
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ANSWER The answer is a . Merkel cell carcinoma is a rare neuroendocrine skin tumour . These carcinomas can metastasise locally or to distant sites . They typically affect elderly Caucasian males and occur on sun-exposed regions . 1 , 2
The clinical presentation of Merkel cell carcinoma is often a rapidly expanding firm erythematous nodule on sun-exposed areas of skin , such as head and neck regions . 1-3 Merkel cell polyomavirus infection is involved in the aetiology of the condition . 2 , 4 . Merkel cell polyomavirus can integrate its DNA into the genome of an immunocompromised host , mediating carcinogenesis . 2 Merkel cell carcinoma can enhance expression of programmed cell death ligand-1 that consequently inhibits T-cell expansion and stimulates exhaustion of T-cells . This stimulates localised immune suppression and tumour immune evasion . 2 , 4 Risk factors for Merkel cell carcinoma include older age , immunosuppression and UV exposure . 1 , 2 A skin biopsy and evaluation of the sentinel lymph nodes are required for diagnosis . 2 , 5
Differential diagnosis includes basal cell carcinoma , squamous cell carcinoma , amelanotic melanoma , pyogenic granuloma , keratoacanthoma and epidermal inclusion cyst . 2 Unlike Merkel cell carcinoma , basal cell carcinomas are usually slow growing , smooth and red . 6 Squamous cell carcinoma is typically keratotic and rapidly growing . 7 , 8 Amelanotic melanoma consists of lesions that are poorly pigmented or non-pigmented and is inversely related to a family history of melanoma . 9 , 10
For local Merkel cell carcinoma lesions , treatment involves local excision . Adjuvant radiotherapy may also be performed locally in low-risk patients . 2 , 5 For patients with Merkel cell carcinoma that has spread to the regional lymph nodes , lymph node dissection is recommended together with radiotherapy . 2 , 5 For metastatic disease , a combination of treatment options may be considered , such as radiation therapy , immunotherapy , chemotherapy and surgery . 2 , 5
In this case , a skin biopsy confirmed localised Merkel cell carcinoma . The patient underwent wide local excision surgery and radiotherapy .
References on request from kate . kelso @ adg . com . au
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