A 52-year-old woman presents to a Jeddah emergency department after two episodes of constricting chest pain at rest during the previous night.
She is currently pain-free and has dyslipidemia, hypertension, and a strong family history of premature coronary artery disease.
Her blood pressure is 146/88 mmHg, pulse is 72/min, and cardiovascular examination is normal without evidence of heart failure.
Serial high-sensitivity troponin measurements are minimally elevated without a significant dynamic change, and echocardiography shows preserved left ventricular systolic function.
The pain-free 12-lead ECG is shown below.
Which investigation is most appropriate next?
The pain-free ECG shows deeply inverted, symmetric T waves in the anterior precordial leads with preserved R-wave progression and no pathological Q waves. Together with recent anginal pain, this is the Wellens pattern, which indicates critical proximal left anterior descending coronary disease. Urgent invasive coronary angiography is required. Stress testing can provoke extensive anterior infarction and should not be performed. This approach is consistent with contemporary ESC acute coronary syndrome guidance for high-risk ischemic ECG patterns.
