Axis: S1 (S wave in lead I), or right axis deviation (S>R in I).Electrical conduction: right bundle branch block.Heart rate/rhythm: sinus tach, atrial fibrillation. ![]() So ECG changes of acute RV strain include: The right ventricle is anterior/inferior, smaller than the left ventricle, and contains the right bundle branch. As McGinn and White first explained in their observation of the S1Q3T3 pattern in 1935, “The changes observed clinically and the electrocardiographic variations in cases showing the acute cor pulmonale consequent to pulmonary embolism are due in large part to dilatation and partial failure of the chambers of the right side of the heart.” So it helps to have a systematic approach to ECG interpretation and to correlate it with the underlying pathology. The ECG can be completely normal in PE, or there can be multiple abnormalities-including rate/rhythm, conduction, axis, R wave progression, voltage and ST/T changes. Old then new ECG:Ĭase 10: 40yo with one week intermittent chest pain, normal vitals. R20 O2 95% HR 80 BP 110/70 afebrile, troponin 100Ĭase 9: 60yo with exertional chest pain and shortness of breath, troponin 150. No pulmonary edema on point of care ultrasound but prominent RV.Ĭase 8: 60yo, no history of lung disease, with two days of ongoing shortness of breath without cough or fever, sent to ED for ‘pneumonia’ based on infiltrate on chest x-ray. Old then new ECG:Ĭase 7: 75yo previously well, with a few weeks of shortness of breath and fatigue, then syncope. R18, O2 96%, HR 110 BP 130/70 afebrileĬase 6: 70yo previously well, presented during the first wave of COVID-19 with two weeks of increasing shortness of breath. No prior ECGĬase 5: 60yo, history of cancer, with two months shortness of breath on exertion. Dilated right ventricle and bilateral pleural effusions on point of care ultrasound. Large RV on point-of-care ultrasoundĬase 4: 80yo with 60 pack-year smoking history, with one month increasing shortness of breath and bilateral leg edema. ECG from first and second visits:Ĭase 3: 85yo with acute on chronic shortness of breath. Returned with increased shortness of breath, tachypnea and hypoxia. Normal vitals and chest X-rayĬase 2: 75yo with exertional chest pain and shortness of breath, normal chest Xray/troponins and discharged. ![]() How does the ECG change your initial management or pre-test probability, and which patients had PE?Ĭase 1: 45yo with 5 days of pleuritic chest pain, and shortness of breath on minimal exertion. 10 patients presented with cardiorespiratory symptoms.
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