A warning sign.

A 64year old man presented with atypical chest pain of 6h duration. Physical examination showed tachycardia and an irregularly irregular pulse. Initial EKG showed atrial fibrillation with rapid ventricular rate. Intravenous Diltiazem was administered following which there was resolution of atrial fibrillation as well as his chest pain. Troponin T and CPK-MB were minimally elevated at 0.05ng/ml (0.0-0.03ng/ml) and 8.6ng/ml (0.0-7.0ng/ml) respectively. A repeat EKG obtained after symptom resolution showed biphasic T wave inversions in V2 and V3 which prompted an emergent coronary angiogram that revealed 90% occlusion of the proximal LAD. The immediate recognition of Wellens' pattern lead to emergent coronary revascularization and prevention of acute myocardial infarction in our patient. Clinicians should be aware of this syndrome so that prompt invasive therapy can be done to avoid evolution into MI and subsequent left ventricular dysfunction.