A Case of Massive Pulmonary Embolism With ST Elevation in Leads V1-4

Abstract

ulmonary embolism (PE) can be difficult to diagnose on clinical grounds as it often presents with nonspecific symptoms. 1 Clinical instability can delay or prevent the execution of an effective diagnostic strategy, with resulting delay in providing appropriate therapy. Prompt diagnosis of PE heavily relies on clinical suspicion. The electrocardiogram (ECG), one of the first examinations to be performed in cases of suspected PE, has been widely studied. 2-7 ECG abnormalities can be seen in 70-80% of patients, varying from the typical S1Q3T3 pattern to no specific changes. However, only very rarely does a PE produce an ECG pattern mimicking acute myocardial infarction (AMI). We describe such a case in the following report. Furthermore, the angiography showed the coronary arteries were normal and the right main pulmonary artery was partially occluded by large pulmonary emboli, despite the acute phase ECG pattern suggestive of AMI, and we recorded in detail the ECG changes which also pointed to the diagnosis of PE. It shows the importance of recognition of various ECG changes in patients with PE. Case ReportA 35-year-old Chinese man was admitted to the hospital because of a 4-week history of a painful right leg. The patient had no significant past medical history and took no medications. The family history was unremarkable for any acute or chronic medical problems. He had no drug allergies and no history of past surgeries, smoking and drinking.He was referred to the radiology department for a Doppler scan of lower extremities. While waiting for the examination, he suddenly collapsed while standing and lost consciousness for approximately 3 min. He recovered spontaneously and had severe chest pain and dyspnea associated with diaphoresis. The patient was then transferred to the cardiology emergency department. In the emergency department, his blood pressure was 72/43 mmHg, his heart rate was regular at 80 beats/min and his respiratory rate was 23 breaths/min. An arterial blood gas test showed an arterial oxygen pressure of 71 mmHg (oxygen saturation was 90%) and a carbon dioxide pressure of 36 mmHg while the patient was breathing 6L of oxygen by face mask.Physical examination revealed a well developed, well nourished man, who knew his identity, whereabouts and the date, and focal neurologic findings were not present when examined. The chest was clear to auscultation and percussion bilaterally. Findings of heart and abdominal examinations were unremarkable, and lower extremities were without edema.Initial investigations revealed that concentrations of complete blood cell count, serum electrolytes, glucose, blood urea and creatinine were normal. The initial ECG ( Figure 1A) showed a normal sinus rate of 80 beats/min with incomplete right bundle branch block (RBBB), ST elevations in leads V1-4, s waves in leads I and V5,6, q wave in lead III. An initial diagnosis of acute anterior myocardial infarction was made. The inotropic agent dopamine was initiated to maintain adequate tissue perfusion, and the patient was administ...

Supradesnivelamento do segmento ST no tromboembolismo pulmonar

“…5 have reported a case of PTE, in which the patient had syncope, chest pain and dyspnea, similarly to the findings of the present report, and the initial ECG, in addition to ST-segment elevation from leads V1 to V4, showed incomplete RBBB, S waves in D1, V5, and V6, and Q wave in D3. Similarly to the case presently reported, the ECG changes normalized with treatment, and the initial diagnosis was AMI 5 . …”

Brugada electrocardiogram associated with pulmonary embolism

“…Anterior ST elevation in PE appears to be a very rare occurrence [2,3] including cases where a transient Brugada pattern has been observed [3]. The mechanism of PE-related anterior ST elevation is debated but according to Dr. Cheng, the most likely mechanism is paradoxical embolization to the left anterior descending coronary artery through a patent foramen ovale [4,5].…”

Massive pulmonary embolism with ST-elevation in the inferior leads and other interesting ECG findings

“…Jia-Feng Lin and Colleagues [4] reported a case about a 35-year-old male with massive PE and ST-elevation in V1-V4. In this study they discussed a combination of hemodynamic, anatomic, metabolic and autonomic effects of acute PE.…”