A 60 yo with chest pain…. deteriorates

This blog is based on a case study in the literature.
A 60 yo male with a recent previous history of angina (with a cardiac stent), has intermittent left sided chest pain. His past medical history is Hypertension and Diabetes. He is haemodynamically stable with a heart rate of 93bpm and Blood Pressure of 122/80 and a respiratory rate of 18.
His ECG shows Q waves in leads III and aVF and his troponin is normal.

4 hours later he crashes,  becomes diaphoretic and tachypnoeic, with a heart rate of 136 bpm and a BP of 70mmHg.
An ECG is done and shown below. Based on this, the patient is taken to the cath lab.
​What does it show? What is the diagnosis?

Match the following percentages with the following symptoms:
79%,   57%,   47%,   26%

1. Pleuritic chest pain
2. Tachycardia
3. Tachypnoea
4. New dyspnoea at rest or exertion

Findings on ECG, for the most, are non-specific for diagnosing pulmonary embolism.
Some of the more typical findings include:

• Sinus Tachycardia
• S1Q3T3
• S1Q3
• Right Axis
• Bundle Branch Block (complete or incomplete)
• T wave inversions in the right precordial leads (right heart strain).

In a study by Sreeram et al, it was found that > 3 of the following increased probability of PE:

• RBBB (complete or incomplete) + STE and positive T wave in V1
• Right axis deviation
• S waves >1.5mm in I and aVL
• Shift of transition zone in precordial leads to V5
• Q waves in III and aVF (but not II)
• T wave inversion in III, aVF, V1-4
• Low voltage QRS in limb leads of <5mm

You can’t remember everything, so look these up next time a patient presents. The ECG must be looked at with the patient’s presenting complaint and past history.
I remember  to look for 5 things:

1. Unexplained Sinus Tachycardia
2. S1Q3T3 or S1Q3
3. RBBB (complete or incomplete) + right axis deviation
   
4. T wave inversion in III and V1-4
5. S wave in I (+ aVL)

Topics on Pulmonary embolism in the members section include:

• The ECGs of Pulmonary Embolism
• ECG findings that predict your patient is about to crash
• What are the symptoms and clinical signs of pulmonary embolism?
• Scoring systems
• Investigations such as the ABG and D-dimer
• PE in Pregnancy
• What about sub-segmental PE’s?
• Who needs thrombolysis?
• The most important studies in management of PE

REFERENCES

1. 1. Villablanca P A et al. Case report and systematic review of pulmonary embolism mimicking ST-elevation myocardial infarction. Vascular 2019, Vol 27(I) 90-97.
      
   2. Falterman TJ, et al. Pulmonary embolism with ST segment elevation in leads V1 to V4: case report and review of the literature regarding electrocardiographic changes in acute pulmonary embolism. J Emerg Med 2001; 21: 255–261. 
   3. Sreeram N, et al. Value of the 12-lead electrocardiogram at hospital admission in the diagnosis of pulmonary embolism. Am J Cardiol 1994; 73: 298–303.