{"id":214330,"date":"2022-06-01T18:15:17","date_gmt":"2022-06-01T21:15:17","guid":{"rendered":"https:\/\/eephcfmusp.org.br\/portal\/online\/?p=214330"},"modified":"2025-07-23T14:12:32","modified_gmt":"2025-07-23T17:12:32","slug":"ecg-sindrome-wellens","status":"publish","type":"post","link":"https:\/\/hcxfmusp.org.br\/portal\/ecg-sindrome-wellens\/","title":{"rendered":"ECG de Wellens s\u00f3 aparece na reperfus\u00e3o?"},"content":{"rendered":"

A s\u00edndrome de Wellens (SW), quadro cl\u00ednico em que aparece o eletrocardiograma de Wellens foi descrita pela primeira vez em 1982, por Zwaan, Wellens et al<\/em>. Tamb\u00e9m \u00e9 conhecida na literatura como s\u00edndrome da descendente anterior e \u201cfazedor de vi\u00favas\u201d.<\/span><\/p>\n

O que \u00e9 S\u00edndrome de Wellens?<\/strong><\/span><\/h2>\n

A SW descreve um paciente com dor tor\u00e1cica com tipo de angina inst\u00e1vel. O padr\u00e3o eletrocardiogr\u00e1fico aparece em momentos de reperfus\u00e3o, ou seja, livre de dor. \u00a0No estudo de valida\u00e7\u00e3o de De Zwann, publicado em 1989 no American Heart Journal<\/a><\/em>, o autor encontrou 180 pacientes com o padr\u00e3o em um per\u00edodo de 5 anos1<\/sup>. \u00a0Ele descreve no artigo que durante a dor tor\u00e1cica as anormalidades de segmento ST e onda T normalizavam ou o paciente tinha supradesnivelamento de segmento ST.<\/span><\/p>\n

O padr\u00e3o de Wellens (Figura 1) \u00e9 descrito como dois tipos: no A, \u00e9 caracterizado por ondas T bif\u00e1sicas em V2 e V3. J\u00e1 o tipo B \u00e9 caracterizado por invers\u00f5es de onda T sim\u00e9tricas e profundas nas mesmas deriva\u00e7\u00f5es. As altera\u00e7\u00f5es podem se estender nas demais deriva\u00e7\u00f5es precordiais. Al\u00e9m disso, o crit\u00e9rio exige que o segmento ST seja isoel\u00e9trico e as ondas Q ausentes.<\/span><\/p>\n

\"S\u00edndrome
Figura 1.Eletrocardiograma com ritmo sinusal e FC de 66bpm, eixo P e QRS normais, onda T com por\u00e7\u00e3o positiva e negativa em V2 e negativa e sim\u00e9trica em V3 e V4 \u2013 demonstrando padr\u00e3o de Wellens.<\/span><\/figcaption><\/figure>\n

O estudo de De Zwann usou como crit\u00e9rio de inclus\u00e3o quadro cl\u00ednico de angina inst\u00e1vel. Em cateterismo coronariano todos os pacientes apresentavam les\u00e3o obstrutiva de coron\u00e1ria descendente anterior. Dos 180 pacientes, 124 foram revascularizados precocemente enquanto 56 permaneceram em tratamento cl\u00ednico inicial. Desse grupo do tratamento cl\u00ednico 26 ainda foram revascularizados tardiamente. Dos pacientes revascularizados 9 pacientes morreram enquanto 8 pacientes morreram do grupo de tratamento cl\u00ednico.<\/span><\/p>\n

Em 2020, outro estudo<\/a><\/strong><\/span> apontou dois casos de pacientes com padr\u00e3o eletrocardiogr\u00e1fico de Wellens, mas assintom\u00e1ticos2<\/sup>. Um paciente foi surpreendido em exames de rotina pr\u00e9-operat\u00f3rios e o outro internou por uma hidradenite purulenta e tamb\u00e9m foi submetido a um eletrocardiograma de rotina. Nenhum dos dois apresentou eleva\u00e7\u00e3o de enzimas, qualquer cl\u00ednica de dor tor\u00e1cica. O segundo paciente teve uma cintilografia que mostrou isquemia moderada na parede anterior e p\u00f3stero-inferior. No relato de caso, os dois foram revascularizados.<\/span><\/p>\n

Ser\u00e1 que essa teria sido a melhor conduta para esses pacientes? Ambos n\u00e3o teriam sido inclu\u00eddos no estudo de De Zwaan, pois n\u00e3o apresentam angina inst\u00e1vel.<\/span><\/p>\n

Nos crit\u00e9rios de adequa\u00e7\u00e3o de interven\u00e7\u00e3o coronariana percut\u00e2nea americana a revasculariza\u00e7\u00e3o da DA proximal em pacientes assintom\u00e1ticos \u00e9 classificada em \u201cpode ser cuidado apropriado\u201d, recebendo nota 4 de um m\u00e1ximo de 9 para consenso de tratamento3<\/sup>. Em pacientes com achados intermedi\u00e1rios em estratifica\u00e7\u00e3o n\u00e3o invasiva o cuidado continua classificado como \u201cpode ser cuidado apropriado\u201d, recebendo agora nota 5.<\/span><\/p>\n

O estudo ISCHEMIA assinalou aleatoriamente 5179 pacientes com isquemia moderada ou grave para estrat\u00e9gia inicial invasiva (angiografia e angioplastia se indicado) ou estrat\u00e9gia conservadora4<\/sup>. O desfecho foi composto por morte cardiovascular, IAM ou interna\u00e7\u00e3o por angina inst\u00e1vel, insufici\u00eancia card\u00edaca ou parada card\u00edaca ressuscitada. Esse estudo n\u00e3o encontrou diferen\u00e7a do desfecho prim\u00e1rio ou de \u00f3bitos nos grupos. Esse estudo incluiu 46,8% dos pacientes com les\u00e3o de DA proximal. Mesmo nesse subgrupo n\u00e3o foi evidenciado diferen\u00e7a de desfecho prim\u00e1rio.<\/span><\/p>\n

Finalmente, na diretriz americana de revasculariza\u00e7\u00e3o coronariana<\/a> de 2021, na se\u00e7\u00e3o de doen\u00e7a isqu\u00eamica est\u00e1vel para pacientes com les\u00e3o obstrutiva de art\u00e9ria descendente anterior com fra\u00e7\u00e3o de eje\u00e7\u00e3o normal a classe de recomenda\u00e7\u00e3o \u00e9 2b. Nos Guidelines<\/em>, a utilidade da revasculariza\u00e7\u00e3o para melhorar a sobreviv\u00eancia \u00e9 incerta5<\/sup>.<\/span><\/p>\n

Pode-se finalmente argumentar que, para les\u00f5es de art\u00e9ria descendente anterior assintom\u00e1ticos, n\u00e3o \u00e9 errado a revasculariza\u00e7\u00e3o, mas ao mesmo tempo, n\u00e3o \u00e9 consenso e o benef\u00edcio incerto. A s\u00edndrome cl\u00e1ssica de Wellens \u00e9 a apresenta\u00e7\u00e3o do ECG durante a melhora da dor, ou seja, a reperfus\u00e3o. Esses casos assintom\u00e1ticos n\u00e3o se encaixam e \u00e9 poss\u00edvel dizer que at\u00e9 pioramos a condi\u00e7\u00e3o desses pacientes que agora tem de usar antiagregantes com os seus riscos inerentes.<\/span><\/p>\n

Dr. Julio Marchini \u00e9 Supervisor do Programa de Resid\u00eancia M\u00e9dica em Medicina de Emerg\u00eancia na USP e um dos coordenadores do curso de <\/span>Medicina de Emerg\u00eancia<\/b><\/a><\/span> do HCX.<\/span><\/span><\/p>\n

Refer\u00eancias:<\/strong><\/span><\/p>\n

    \n
  1. de Zwaan, C. et al.<\/em> Angiographic and clinical characteristics of patients with unstable angina showing an ECG pattern indicating critical narrowing of the proximal LAD coronary artery. American Heart Journal<\/em> 117<\/strong>, 657\u2013665 (1989).<\/span><\/li>\n
  2. Torelli, E. et al.<\/em> Wellens Syndrome without chest pain, is it possible? European Review for Medical and Pharmacological Sciences<\/em> 24<\/strong>, 7718\u20137721 (2020).<\/span><\/li>\n
  3. Patel, M. R. et al.<\/em> ACC\/AATS\/AHA\/ASE\/ASNC\/SCAI\/SCCT\/STS 2017 Appropriate Use Criteria for Coronary Revascularization in Patients With Stable Ischemic Heart Disease. Journal of the American College of Cardiology<\/em> 69<\/strong>, 2212\u20132241 (2017).<\/span><\/li>\n
  4. Maron, D. J. et al.<\/em> Initial Invasive or Conservative Strategy for Stable Coronary Disease. N Engl J Med<\/em> 382<\/strong>, 1395\u20131407 (2020).<\/span><\/li>\n
  5. Lawton, J. S. et al.<\/em> 2021 ACC\/AHA\/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology\/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation<\/em> 145<\/strong>, (2022).<\/span><\/li>\n<\/ol>\n","protected":false},"excerpt":{"rendered":"

    A s\u00edndrome de Wellens (SW), quadro cl\u00ednico em que aparece o eletrocardiograma de Wellens foi descrita pela primeira vez em 1982, por Zwaan, Wellens et al. Tamb\u00e9m \u00e9 conhecida na literatura como s\u00edndrome da descendente anterior e \u201cfazedor de vi\u00favas\u201d. O que \u00e9 S\u00edndrome de Wellens? A SW descreve um paciente com dor tor\u00e1cica com […]<\/p>\n","protected":false},"author":16598,"featured_media":390680,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[390],"tags":[],"class_list":["post-214330","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-blog"],"yoast_head":"\nECG de Wellens s\u00f3 aparece na reperfus\u00e3o? - EEP HCFMUSP<\/title>\n<meta name=\"description\" content=\"A S\u00edndrome de Wellens (SW), com padr\u00f5es de ECG caracterizado por ondas T profundamente invertidas, s\u00f3 aparece reperfus\u00e3o? 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