Instructive ECG series in massive bilateral pulmonary embolism

Abstract

The ECG is abnormal in over 70% of patients with pulmonary embolism. Certain ECG abnormalities have been observed to return to normal after treatment. This case report describes an instructive ECG series in a patient with massive bilateral pulmonary embolism as shown by spiral computed tomography. The initial ECG showed sinus tachycardia with P pulmonale, although atrial tachycardia could not definitively be excluded. The patient had an increased troponin I concentration and echocardiographic evidence of right ventricular dysfunction and underwent thrombolysis with alteplase and anticoagulation with warfarin. P wave amplitude gradually decreased throughout admission and her tachycardia resolved. This may reflect a reduction in right atrial strain after treatment. This phenomenon has apparently not been described in this setting. The significance of ECG changes and the role of thrombolysis in pulmonary embolism are briefly discussed.A 61 year old retired nurse was referred by her general practitioner to the casualty department with breathlessness and central chest tightness, which was pleuritic and not associated with palpitations or autonomic symptoms. She had no cough or haemoptysis. For the preceding nine months she had also noted a swollen, tender left leg, in which she was known to have varicose veins. She took hormone replacement therapy (HRT) for post-menopausal symptoms. She had no other risk factors for venous thromboembolism or ischaemic heart disease. The patient was ambulant and independent with respect to activities of daily living. She was a non-smoker and only occasionally drank alcohol.On examination, her temperature was 37.8˚C. Heart rate was 140 beats/min, and blood pressure was 140/80 mm Hg. Jugular venous pressure was not reported to be increased. Heart sounds were normal. Arterial blood gases on air were within normal limits, with oxygen saturation of 99% on air. Her respiratory rate was 16 respirations/min. Her chest was clear to auscultation. There was bilateral pitting oedema, more so in the left leg, in which there was evidence of varicose veins. The left leg was not tender to palpation and was not erythematous. The chest radiograph and other examination were unremarkable.Blood results were as follows: haemoglobin 8.25 mmol/l, white cell count 3.6 6 10 9 /l, platelets 266 6 10 9 /l, C reactive protein 20.1 mg/l; sodium 134 mmol/l, potassium 4.2 mmol/ l, urea 4.9 mmol/l, creatinine 73 mmol/l; albumin 36 g/l, total protein 68 g/l, alkaline phosphatase 108 IU/l, bilirubin 3 mmol/l, alanine transaminase 113 IU/l; thyroid stimulating hormone 31 mIU/l; and free thyroxine 11.7 pmol/l.A screening echocardiogram showed a dilated hypokinetic right ventricle. A working diagnosis of pulmonary embolism (PE) was made. Subcutaneous enoxaparin and analgesia were administered, and antiembolic stockings were applied. HRT was stopped. The initial ECG showed a tachycardia with tall P waves and low voltage QRS complexes (fig 1). Since atrial tachycardia was considered in the differential diagnosis, adenosine ...

Association Between Electrocardiographic Findings, Right Heart Strain, and Short‐Term Adverse Clinical Events in Patients With Acute Pulmonary Embolism

“…It is estimated that 70% of PE patients have abnormal ECG recordings. 5 Certain ECG findings with PE may suggest right heart strain (RHS) and therefore might be used to prioritize care in these high-risk patients. 6 -9 As echocardiography is not routinely available during all hours of the day in many medical centers, 10 ECG could be a useful tool for risk-stratifying PE patients.…”

Elevation of troponin values in differential diagnosis of chest pain in view of pulmonary thromboembolism

“…We were directed to PE as differential possibility by cardiac ultrasound which showed a borderline dimension of the RV which is an independent predictor of mortality and non-fatal clinical complications in PE 11 and enlarged values of D-dimer after performed coronarography, although our patient had intermediary Geneva (3 poens) and low Well (0 poen) score 12 . We should say that appearing of opposite T waves in precordial leads, was shown in our case, could be one of signs of PM 13 . The reported sensitivities and specificities for the diagnosis of PE of spiral CT vary (45%-100% and 78%-100%), and depend on the type of CT (single or multi-detector spiral CT).…”

New onset S wave in pulmonary embolism: revisited (something old and something new)

“…But unknown to us, Todd has showed an S wave disappearing after embolectomy for pulmonary embolism. We would also like to report the article of Cheng10 that was published in Heart 2005, here the authors show that a large P wave in lead 2 regressed after thrombolysis with alteplase. The ECGs are beautifully shown in this article.…”