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Acute coronary syndrome is a leading cause of mortality and morbidity worldwide, requiring emergency care and admission. Wellens syndrome is a preinfarction state that may not have the classic electrocardiographic findings expected with other forms of acute coronary syndrome or the elevated cardiac enzymes. This lack of typical changes in electrocardiography provides a clinical challenge for diagnosis. The ability to promptly identify and treat this time-sensitive state of potential myocardial infarction and death has a significant prognostic value that cannot be overstated. •Acute coronary syndrome may present with various electrocardiographic morphologies.•Wellens syndrome is a preinfarction state with distinct electrocardiographic changes in the precordial leads.•Wellens syndrome is highly specific for proximal stenosis of the left anterior descending coronary artery.•Medical management and cardiac catheterization are usually required for treatment.•Nurse practitioners should identify these patients as they present to the emergency department.