Wellens' syndrome following severe COVID-19 infection, an innocent coincidence or a deadly association: two case reports

Abstract

Background: Coronavirus disease 2019 (COVID-19) has been associated with late-onset cardiovascular complications primarily due to a hypercoagulable state. Its association with Wellens' syndrome, which reflects a stenosis in the proximal left anterior descending coronary artery, is not well established. We present two cases diagnosed with this syndrome following their COVID-19 acute phase despite taking adequate anticoagulation.

Case presentation: We present two patients with incidental electrocardiography (ECG) showing the typical Wellens'-related changes, with an underlying severe triple-vessel coronary artery disease a few weeks following a severe COVID-19 infection associated with high inflammatory markers. The stenotic lesions were diagnosed by cardiac catheterization, and both patients underwent Coronary Artery Bypass Grafting successfully. Notably, patients' baseline ECGs were normal, and they were maintained on Rivaroxaban 10 mg following their viral illness.

Conclusion: Despite advances in the preventive measures for COVID-19 complications, its pathophysiologic impact on vasculature and atherosclerosis is still incompletely understood. Further clinical trials must be conducted to study this association between Wellens' syndrome and this virus to prevent life-threatening complications.

Keywords: Acute coronary syndrome; Atherosclerosis; COVID-19; COVID-19 complications; Wellens’ syndrome.

Fig. 1

1.a. First patient’s ECG: Sinus rhythm with a 1 mm ST-segment elevation and a biphasic T-wave in V2 and V3 precordial leads; T-wave inversion in V4, V5, and V6 leads. Absence of pathological Q-wave in these leads preserved R-wave progression from V1 to V6. 1.b. Second patient’s ECG: Sinus rhythm with a 2 mm ST-segment elevation and a biphasic T-wave on V2, V3, V4, and V5 precordial leads. Absence of pathological Q-wave in these leads and preserved R-wave progression from V1 to V6

Fig. 2

The patients’ coronary angiography- part 1. Patient 1 2. a. Long mid-segment of 70–80% stenosis in the LAD, 50% ostial stenosis in the first diagonal coronary artery (DCA), mid-segment 95% thrombotic stenosis in the Second DCA, and proximal 70–80% stenosis in the circumflex coronary artery (Cx). 2. b. Mid-segment chronic total occlusion of the right coronary artery (RCA) with bridging collaterals. The posterior descending artery (PDA) and posterior left ventricular artery (PLV) fill retrogradely from collaterals arising from the LAD septal branches. Patient 2 2. c. Ostial-mid long segment of 80–90% stenosis in the LAD, sub-total occlusion of the First DCA and Cx, and proximal 80% stenosis in the first obtuse marginal (OM1). 2. d. 80% stenosis of the mid RCA and ostial 80% stenosis of the PDA. The PLV has a chronic total occlusion proximally and is receiving collaterals distally from the distal PDA

Fig. 3

The patients’ coronary angiography- part 2. Patient 1:3. a. The Circumflex coronary artery has a proximal 70–80% stenosis with diffuse atherosclerosis. Patient 2 3. b. The circumflex coronary artery has mild diffuse disease with subtotal occlusion in the small mid-distal circumflex proper just after the bifurcation of Obtuse Marginal 1 (OM1). OM1 is medium size vessel with a proximal 80% stenosis followed by diffuse disease