A woman in her 40s with acute chest pain and shortness of breath

Written by Pendell Meyers

A woman in her 40s presented with acute chest pain and shortness of breath. Vitals were within normal limits. 

Here is her triage ECG:

What do you think?

Smith: This is classic for pulmonary embolism (PE).  There are 2 key points to making this diagnosis on the ECG:

1) There is T-wave inversion which you might think is due to Wellens' waves, but the patient has active symptoms, so it is not Wellens' sydrome

2) The T-wave inversion in V1-V4 is accompanied by T-wave inversion in lead III.  This is very specific for PE vs. ACS.

Also, and much less teachable: the T-waves just don't look right for ACS.

Check out this post for an explanation of the T-wave morphology:

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Acute right heart strain was suspected on ECG and bedside echo.

Acute pulmonary embolism was confirmed on CT angiogram:

The patient did well.

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

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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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MY Comment, by KEN GRAUER, MD (11/21/2024):

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Today's case by Dr. Meyers serves as one more reminder of an entity that we need not to miss = Acute PE (Pulmonary Embolism).

• At the end of Dr. Meyers' discussion — he lists more than 20 links to cases that we've presented related to this entity on Dr. Smith's ECG Blog. That said — the diagnosis of acute PE continues to be overlooked (and the ECGs of such patients continue to be misinterpreted as acute ischemia or infarction — instead of being recognized as diagnostic of acute PE).

The ECG Diagnosis of Acute PE:

We've reviewed the ECG clues to acute PE in those more than 20 links that Dr. Meyers' lists above. I found today's initial ECG interesting — in that most of the time, the ECG diagnosis of acute PE is highlighted by more than just a couple of the ECG Findings that I list below in Figure-2.

• For example, in today's initial ECG (that I've reproduced and labeled in Figure-1) — there is no sinus tachycardia — and no right axis, RAA, incomplete or complete RBBB, tall R in lead V1, persistent precordial S waves, ST elevation in lead aVR or AFib.

That said — the following are present in today's case:

• A suggestive History (shortness of breath with chest pain as the chief complaint).
• An S1Q3T3.
• Deep symmetric T wave inversion in the anterior chest leads (BLUE arrows in Figure-1) — that occurs in association with T wave inversion suggesting RV "strain" is present not only in the anterior chest leads, but also in inferior leads III and aVF.

PEARL (as per Drs. Meyers and Smith): When there is T wave inversion in the chest leads — IF there is T wave inversion in both lead V1 and lead III ==> Think acute PE (and not ACS! ).

• By itself — the S1Q3T3 sign seen in Figure-1 would not be specific for acute PE (ie, I have seen this sign in healthy individuals with no acute pulmonary pathology). However, in the presence of a suggestive history and the extensive T wave inversion seen in today's case — the S1Q3T3 strongly supports the diagnosis of acute PE.
• T wave inversion as diffuse as is seen in Figure-1 — most often suggests a sizeable PE (which makes it all the more surprising that there is no tachycardia and a lack of more of those ECG findings that are listed in Figure-2).
• Finally — the Q in lead III — the ST coving with slight ST elevation + T wave inversion in leads III and aVF — and the ST segment straightening in lead aVL — might lead one to misinterpret today's ECG as indicative of ACS. IF tempted to do so — it is worth rereading the above PEARL!
• CT angiogram confirmed the diagnosis of acute PE.

Figure-1: I've labeled the initial ECG in today's case.

Figure-2: ECG Findings associated with acute PE.