Pseudo-Wellens Syndrome: Demonstrating the Importance of Electrocardiogram in Emergency Psychiatric Patients

Introduction Pseudo-Wellens syndrome (PWS) is a rare but clinically significant condition characterized by electrocardiogram (ECG) abnormalities that mimic acute ST-segment elevation myocardial infarction (STEMI) in the absence of obstructive lesions on coronary angiography. The occurrence of PWS should be on the differential for any patient who visits the Emergency Room (ER) with known and/or suspected drug overdose. This will avoid the potential for inappropriate invasive diagnostic modalities in otherwise cardiac healthy individuals. This literature review aims to explore the ECG changes in patients diagnosed with PWS in the context of drug intoxication presenting to the ER. Methods Specific keywords such as "Pseudo-Wellens Syndrome," "ECG/EKG,” and "substance abuse," were used to search PubMed, Google Scholar, and PsycInfo. Articles on PWS that were not on patients presenting with substance use or not in English were removed. We extracted substance use history, ECG parameters, and their clinical presentations to the ER for review. Results We found cases of PWS in patients presenting with cannabis, PCP, methamphetamine, opioid, and cocaine intoxication, either in combination or singularly. The most common ECG finding across the cases was biphasic T wave inversion in V2 and V3 with involvement in the anterior leads. The authors were unable to find any characteristic ECG changes associated with individual substances. This might be attributed by the small number of patients in the studies and due to the use of multiple drugs by patients at presentation to the ER, especially with drugs known to cause ECG abnormalities such as opioids. While PWS typically resolves spontaneously in most cases, this review revealed a concerning trend. Patients who consumed cocaine were at a higher risk of developing life-threatening cardiac conditions, including myocardial infarction. This finding underscores the importance of considering the pretest probability of acute coronary syndromes and avoiding misinterpretation of PWS as a less severe entity. For those patients presenting with a suspicious diagnosis and high pretest probability indicating an interruption of coronary blood flow, a comprehensive work up should be done to investigate any other possible life-threatening cardiac conditions. Conclusions PWS has ST segment and T wave abnormalities, which are ECG abnormalities that are already very common in psychiatric patients seen in-hospital. Recognizing the specific ECG findings in PWS is of utmost importance for clinicians to prevent unnecessary interventions and potential harm to patients. For further understanding, more comprehensive analysis of ECG findings with larger sample sizes while considering comorbid conditions and contributing factors to the patient presentation should be conducted. Funding No Funding