Saturday, April 2, 2011

Is it pulmonary embolism?

This is a 41 year old male with severe asthma who barely avoided intubation.  His troponin returned at 0.13, and here is his ECG:

There is sinus tach with anterior T-wave inversion of the same morphology as the previous cases of PE which I have posted (see link below).  There is no TW inversion in lead III, so this is not pathognomonic.  Whether or not there is T-wave invesion, this ECG could be due to PE or any cause of right heart strain.


Here are some cases of pulmonary embolism.


This is to illustrate that these T-wave inversions are due to acute right heart strain, which is caused by many etiologies other than PE, including but not limited to acute severe asthma and acute pneumonia.  Hypoxia causes pulmonary vasoconstriction (pulmonary hypoxic vasocontriction) which puts strain on the right heart.

Pulmonary embolism was ruled out.

8 comments:

  1. It could be Wellens', but it has a different look than Wellens' because of the humped look of the T-wave. All I can do is refer you to a couple Wellens' cases, and contrast with PE cases further down

    Wellens: http://hqmeded-ecg.blogspot.com/2011/05/wellens-missed-then-returns-with.html

    Wellens: http://hqmeded-ecg.blogspot.com/2011/03/classic-evolution-of-wellens-t-waves.html

    Another pulm embolism: http://hqmeded-ecg.blogspot.com/2011/03/chest-pain-sob-anterior-t-wave.html

    Another pulm embolism: http://hqmeded-ecg.blogspot.com/2010/03/anterior-t-wave-inversion-due-to.html

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  2. so if there are twi in lead iii then it cant be pneumonia/asthma?

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    1. No. One cannot tell the difference on the ECG among these etiologies of acute right heart strain. Even TWI in lead III won't help you.

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  3. Dr. Smith,
    could it not look like evolving MI changes in anterior leads? i know there are no q waves in these leads?

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    1. It is possible, but it looks far more like right heart ischemia. It is difficult for me to explain why. Partly because of the tachycardia. Look at the other examples of pulmonary embolism and compare to Wellens'. They just look different.

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  4. Dr Smith, have you got any ECg or text on coronary sinus rhythm? if yes, please publish it. I had a patient recently who had inverted p waves in all his leads on ECg and it turned out to be a coronary sinus. i needed more information on that.

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    1. This is something that I don't know a lot about, but also don't see what its importance is. There is a lot of literature on it, but why do you find it important? If there is an ectopic atrial rhythm originating near the coronary sinus, changing P-wave morphology, does that change any patient management?
      Steve Smith

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