Case 9

Stem: Twenty one year old man with L sided pleuritic chest pain. He has been a paraplegic (T6 level) since a motor cycle accident 5 years ago. He is currently being treated for testicular cancer.

+ List the significant findings in the ECG, and provide the most likely or important diagnosis

  • The rhythm is regular. Sinus tachycardia is present at a rate of about 100 beats per minute. The PR, QRS and QT intervals are normal. The transition zone is in Lead V3
  • The P waves are normal, and the frontal plane QRS axis is rightward at about 80 degrees. Right bundle branch block is present (S wave in Leads I and V6, and R waves in Leads V1 and V2); as the QRS width is normal this is a incomplete right bundle branch block.
  • Lead V1 has a low amplitude QRS complex, with a R wave amplitude that is tall when compared to the S wave. The T wave in Lead V1 is inverted (this can be a normal finding). The R wave in Lead V2 is tall. The T waves in Leads V2 to V6 are low amplitude. There is slight J point depression and up-sloping ST depression in Leads V4 to V6
  • Q waves are present in Leads II, III and aVF, and there is T wave inversion in Leads III and aVF.
  • A S1Q3T3 pattern is present
  • The clinical setting and the ECG findings are consistent with acute pulmonary embolism

Notes:

  1. CTPA showed bilateral emboli in the inferior branches of the pulmonary artery. There were also multiple metastatic nodules in the lungs
  2. The ECG may be normal in acute pulmonary embolism or the findings non-specific. One or more of the following changes may be seen:
    • Sinus tachycardia*
    • Rightward axis* or right axis deviation (but left axis deviation and an indeterminate axis have also been seen in acute pulmonary embolism)
    • S1Q3T3*: present in about 1 in 5 cases of pulmonary embolus, but a similar pattern is also seen in some normal ECGs
    • [New or presumably new] right bundle branch block (complete or incomplete*)
    • T wave inversion in the inferior leads*† or in Leads V1-V3†. The presence of T wave inversion in these leads is sometime called "right heart strain"
    • qR morphology in Lead V1
    • ST elevation in Lead aVR† ± ST elevation in Leads V1 - V3†
    • Other non-specific ST - T changes*
    • Atrial premature complexes or atrial arrhythmias (atrial flutter, atrial fibrillation)
    • P pulmonale

*Seen in this case
† Can mimic acute myocardial ischaemia