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Landmines that Kill on the 12 Lead EKG: Wellen’s Sign

John Bielinski, MS PA-C By July 29, 2014April 2nd, 2017No Comments

There are some sneaky findings on an EKG that are landmines. Wellen’s Sign is one.

A closer look at Wellen’s Sign on an EKG

As first described in the 1980’s, the findings of Wellen’s Sign identifies a subset of patients that are in trouble. It’s a warning EKG finding – one that says, “This patient has a widow-maker LAD lesion and is going to die.” Sure, this is a warning, but also a gift. This is a red flag finding that demands revascularization – or at least a look at the vessels by an interventionist.

Recognizing Wellen’s Sign on an EKG

So, what are the findings? If you look at Wellen’s Type 1, there are deep T-wave inversions in V2 and V3. Now even if you didn’t know this was called “Wellen’s Sign,” you would not send this patient home. They are coming in for admission, getting ASA, anticoagulation and cardiology consultation. These findings suggest to me a posterior wall AMI. I feel the danger is in the subtle findings of Wellen’s Type 2.

Remember this is a preinfarction stage of coronary artery disease, also referred to as “LAD coronary T-wave syndrome.”

What are the criteria, you ask?

1) History of angina + T wave inversion or biphasic t waves in V2–V4
2) Normal or minimally elevated cardiac enzymes
3) No pathologic precordial q waves or loss of precordial R wave progression


The above example is pretty impressive. If you look at the deep, biphasic T waves in V2 and V3, that’s impressive, as well as the deep and symmetrical T-wave inversion in V4.

Not-so-obvious Wellen’s Sign on an EKG

Now, what if Wellen’s is not so obvious on an EKG? The good news is, even if you don’t know the exact name of the sign, but your EKG skills are sound, you will pick up the funky T waves and question them.

The two safety nets I always teach with 12 Lead EKGs are:

1) Phone a friend (get another set of eyes on the EKG)
2) Repeat the EKG (especially if the patient is having chest pain)

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