Wednesday, December 13, 2017

A 30-something woman with chest pain and h/o pulmonary hypertension due to chronic pulmonary emboli

A 30-something woman with known history of pulmonary hypertension due to chronic pulmonary emboli presented with 12 hours of substernal chest pain.

Here was her ED ECG:
What do you think?























This precordial T-wave inversion is typical of right ventricular hypertrophy (RVH).  However, most other features of RVH are not present.  There is an incomplete RBBB, which does support RVH.  But there is no right axis deviation (axis is however borderline at 83 degrees, nearly vertical.  There is no large R-wave in V1.  However, these findings are not sensitive enough for RVH to rule it out.

The T-wave morphology, along with the known history of pulmonary hypertension, should alert you to look for a previous ECG.

I saw this and thought immediately that this was probably her baseline EKG.  We looked for old ones, and indeed previous ECGs were identical.

The patient ruled out for both PE and MI while in the ED, and could be discharged.  This was her baseline ECG.  Our diagnosis was gastroesophageal reflux.



Here are a couple other cases of RVH:

55 year old woman with chest pain and precordial T-wave Inversions

This one does have right axis deviation and a large R-wave in V1






A 50-something male with Dyspnea
This one also has right axis deviation and a large R-wave in V1

15 comments:

  1. How is PE ruled out in ED?

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    1. D dimer. Can't remember if we did a CT too.

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  2. The ST depressions in v2 v3 v4 are concordant STd.. Isnt RVH(also IRBBB) supposed to produce discordant ST depressions/elevations??

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    1. Only if there is complete RBBB or LBBB

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  3. Perhaps the most difficult (and most overlooked) diagnosis for clinicians is recognition of RVH in adults. The reasons for this are simple. Left ventricular mass in adults dramatically overwhelms right ventricular mass. As a result, a predominant R wave in right-sided lead V1 is only seen with RVH in adults when RVH is marked, and/or with end-stage pulmonary disease; and/or when there is pulmonary hypertension. No one single ECG finding is diagnostic of RVH — but rather it is a combination of findings in the right clinical setting that makes the diagnosis. As per Dr. Smith — the only definitive finding in support of RVH on this tracing is RV “strain” (ie, the prominent anterior T wave inversion). That said, there are other subtle indicators consistent with RVH. The axis is more inferior than usual (S wave in lead I nearly as deep as the R in lead I is tall) — a relatively tall and definitely pointed initial P wave component in leads V1,V2 (which is suggestive of RAA) — the rSr’ pattern in V1 — persistence of some s wave in lead V6 (in totally normal tracings, the S wave has disappeared by leads V5,V6). While clearly none of these features alone would be diagnostic of RVH — in combination, they should strongly suggest this possibility. Waiting for a predominant R wave in lead V1 would miss many cases in which RVH was present. Finally, as noted — PE should be ruled out (as was done), given the anterior T wave inversion as seen here. It’s always instructive to review the many variant patterns of ECG RVH — Thanks to Dr. Smith for presenting.

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  4. Could the last ecg in this post have Wellen's warning?

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    1. The last ECG is a down up T-wave, not an up-down T-wave. It could look like that in either posterior MI or hypokalemia. But not Wellens'.
      See this post: http://hqmeded-ecg.blogspot.com/2016/11/biphasic-t-waves-in-middle-aged-male.html

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  5. Quick question! How can we be sure that the patient has right Axis deviation in the last 12-lead? I see that lead 1 is the isoelectric lead which puts us around 90 degrees because of the positive QRS in AVF, but it seems that the R wave is ~ 7mm while the S wave is ~ 6mm in lead 1. Thus, moving the QRS Axis 10 degrees towards the positive pole of lead 1 which gives us ~ 80 degrees. There has to be something I'm missing here? Also, do we always need the RAD to confirm RVH w/ "strain" or is the strain pattern enough?

    Thank you Dr. Smith,
    Octavio

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    1. Octavio,
      I wrote that there is NO right axis deviation:
      "But there is no right axis deviation (axis is however borderline at 83 degrees, nearly vertical....."
      Steve

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    2. My apologizes! Moreover, I was referring to the 50-something male w/ dyspnea. The Axis for that one is quite vertical as well correct? Thank you for your reply Dr. Smith!

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    3. I'd like to also respond to Octavio. As per Dr. Smith, there is no right axis by the definition most commonly used ( = an axis more rightward than +90 degrees in adults). That said, as per my detailed comment a bit above your question — the diagnosis of RVH in adults is most often quite subtle. It is not made by any single finding — but rather by a combination of suggestive findings occurring in context of a clinical situation in which RVH might be anticipated. The point I was making in my earlier comment was that in this "high prevalence situation" (ie, a woman with pulmonary hypertension) — I take subtle partial clues (ie, an axis more rightward than what one usually expects in a normal adut tracing, albeit NOT satisfying criteria for actual "right axis deviation") + an rSr' in V1 + persistence of some s wave thru to V6 + a pointed positive P wave component in V1,V2 (which doesn't fit the "usual" RAA criteria, but which in my experience IS clearly correlated with RAA in situations like these) — as STRONG suggestion that actual RVH does exist in this patient who has a pronounced anterior lead RV "strain" pattern. I hope the above "detective work" makes sense — :)

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    4. Thank you so much for taking your time and explaining this to me. It makes perfect sense and I have a greater understanding now. I am extremely passionate for electrophysiology and cardiology so your reply means a lot! Thank you Doctor.

      Octavio

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  6. Why there is only precordial T wave inversion in RVH... Can u explain T wave inversion with electrophysiology connection.?

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    1. I don't know. It just is that way. An abnormal QRS leads to abnormal ST-T.

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