Tuesday, March 26, 2024

A man in his 50s with shortness of breath

Sent by Tom Fiero, written by Pendell Meyers


A man in his 50s presented with acute shortness of breath. Unfortunately we do not have access to the patients presenting vital signs.

Here is his ECG:

Original image, suboptimal quality

Quality improved with PM Cardio digitization

The ECG is highly suggestive of acute right heart strain, with sinus tachycardia, S1Q3T3, and T wave inversions in anterior and inferior with morphology consistent with acute right heart strain. There is also STE in lead III with reciprocal depression in aVL and I, as well as some subendocardial ischemia pattern with STD in V5-V6 and STE in aVR. Thus, the ECG could be considered similar to Aslanger's pattern (inferior OMI plus SEI pattern). We have seen this pattern in many pts with acute right heart strain on this blog.



The combination of T-wave inversion in V1-V3 and in lead III is very specific for acute pulmonary embolism.  Aslanger's is a combination of acute inferior OMI plus subendocardial ischemia, and due to the ischemia vectors, it has STE only in lead III.  It usually presents with an upright T-wave in both precordial leads and in lead III.  

The ECG in this case has an inverted T-wave in both precordial leads and lead III. 

Moreover, what I call "domed" T-wave inversion in V1-V3 is typical for acute PE and NOT typical of ACS (i.e., Wellens'), presumably because the source of the T-wave inversion is RV strain, not LV ischemia.  Moreover, there is tachycardia. Moreover, T-wave inversion in V1-V3 due to ACS is typically seen in reperfusion states when the patient is symptom free.  So everything about this ECG screams acute PE.

No doubt the patient also had hypoxia with no B-lines, clear lungs on auscultation, and no infiltrate or pulmonary edema on chest X-ray, all of which would shout "Pulmonary embolism".  Unfortunately, we don't have those details.

See 4 examples of Aslanger's pattern here: only one has an inverted T in lead III, but with definite ST elevation and also with upright T-waves in V1-V3.


Queen of Hearts:

Overall Interpretation: Not OMI High Confidence, despite noticing the signal mentioned in III and aVL.

Version 1 of Queen of Hearts does not diagnose any other ECG-identifiable condition besides OMI.  Since then, we have taught her to recognize acute right heart strain.  Thus, later versions may be able to diagnose this acute right heart strain pattern!

Further history also revealed a recent knee surgery, and being off of rivaroxaban for unclear reasons.

Acute pulmonary embolism was confirmed on CT:

The patient did well with treatment.

The Queen of Hearts PM Cardio App is now available in the European Union (CE approved) the App Store and on Google Play.  For Americans, you need to wait for the FDA.  But in the meantime:


If you want this bot to help you make the early diagnosis of OMI and save your patient and his/her myocardium, you can sign up to get an early beta version of the bot here.  It is not yet available, but this is your way to get on the list.

See our other acute right heart strain / pulmonary embolism cases:

A man in his 40s with RUQ abdominal pain

A woman in her 50s with shortness of breath

A crashing patient with an abnormal ECG that you must recognize

A man in his 40s with a highly specific ECG

Chest pain, ST Elevation, and tachycardia in a 40-something woman

Repost: Syncope, Shock, AV block, RBBB, Large RV, "Anterior" ST Elevation in V1-V3

A young woman with altered mental status and hypotension

An elderly woman transferred to you for chest pain, shortness of breath, and positive troponin - does she need the cath lab now?

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

A 30-something with 8 hours of chest pain and an elevated troponin

Syncope, Shock, AV block, Large RV, "Anterior" ST Elevation....

Dyspnea, Chest pain, Tachypneic, Ill appearing: Bedside Cardiac Echo gives the Diagnosis

31 Year Old Male with RUQ Pain and a History of Pericarditis. Submitted by a Med Student, with Great Commentary on Bias!

Chest pain, SOB, Precordial T-wave inversions, and positive troponin. What is the Diagnosis?

Cardiac Ultrasound may be a surprisingly easy way to help make the diagnosis

Answer: pulmonary embolism. Now another, with ultrasound....

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

Chest Pain, SOB, anterior T-wave inversion, positive troponin

Anterior T wave inversion due to Pulmonary Embolism

Collapse, pulse present, ECG shows inferior OMI. Then there is loss of pulses with continued narrow complex on the monitor ("PEA arrest")

What do you suspect from this ECG in this 40-something with SOB and Chest pain?

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