Wednesday, March 30, 2011

This is a quiz. The ECG is nearly pathognomonic. Answer at bottom.

A 38 year old with chest pain and SOB:

The answer can be found here (a different example of the same pathology, with explanation):


  1. I vote for pulmonary embolism, the ST-T changes in V1-V2 are very concerning. If this patient is crashing this ECG is enough to allow a presumptive diagnosis and treatment for PE. The patient may well have a dilated RV on bedside ECHO for confirmation of diagnosis, especially important if not stable enough for CTPA.
    My 2 cents, Dr. J

  2. I believe the image in the prompt is different than the one shown on the answer page

  3. Yes!! Sorry, I was giving you yet another example and explanation.

  4. there are responses on facebook that, to paraphrase, say this isn't pathognomonic for PE, but there are only non-specific changes. what do you say to them?

  5. I don't know what they are saying, but I should clarify that it is nearly pathognomonic for acute right heart strain, which is usually PE.

  6. It is the precordial T-wave morphology, along with tachycardia and T-wave inversion in lead III, that makes this pathognomonic. I'd love to see examples with the same findings that are not PE. I bet that I will receive cases of ACS T-wave inversion that I could differentiate from PE. The difficulty is to describe what it is about the morphology of the precordial T-waves that I find pathognomonic. Not sure I can do that.

    In any case, if I am sent such ECGs through, I will post them and describe them. If I'm wrong I'll be the first to say so.

  7. There is Sinus tachicardia, deep S in lateral leads due to left anterior hemi block,Cornel criteria for LVH,biphasic T wave in V1,v2,v3.negative T wave in III lead followed negativ rS complex which can be normal sign.

    there is no P pulmonale,no RBBB,no right axis deviation and no s1q3te pattern....

    what in this ecg is patognomonic for acute pulmonary embolism????

  8. OK, some people are upset that I called this pathognomonic. I should say "nearly pathognomonic in the clinical context." I should say also that when I see an ECG like this I know immediately that it is acute heart strain and I have yet to be wrong. There is more to it than just the sinus tach and T-wave inversion in V1-V3 and also lead III; there is also the morphology of the T-wave inversion. It just doesn't look like the T-waves of anterior ACS (Wellens'); nor do they have the morphology of T-waves from LVH.

    So here is a challenge: send me an ECG from a patient with chest pain and SOB that looks like this or any of the others in the link associated with this case that is NOT due to PE. You may find one; I would find it very interesting and I'll post it. Send to:

  9. Could you comment on QT interval in acute right heart strain ? Is this one of the attributes differentiating its negative precordial T waves from ischemic ones ?

    1. Good question, but I don't know! I suspect it is prolonged.
      Steve Smith