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
- CTPA showed bilateral emboli in the inferior branches of the pulmonary artery. There were also multiple metastatic nodules in the lungs
- 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