What would be your threshold to offer coronary angiography for patients presenting with atypical chest pain features and Wellens syndrome on EKG without a troponin elevation or dynamic EKG changes?

In three words- very low threshold.

Wellens syndrome typically presents with T-wave inversion in V 2, 3, but can be across the precordium. The patient may be asymptomatic at the time of presentation, but Wellen probably represents a pre-infarction state representing proximal LAD thrombus. The proposed mechanism is clot lysis prior to full infection. Classically, troponins of the negative upon presentation. I suspect with high-sensitivity troponins being widely used now, the chances of positive troponins are significantly higher. Of note, critical stenosis of the RCA, and circumflex have been found with similar T-wave abnormality in respectively leads.

Typically, these patients are best evaluated by proceeding directly to cardiac catheteriza...