TELL-TALE T WAVES IN ACUTE PULMONARY EMBOLISM

Abstract

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: An electrocardiogram (ECG) can give us many clues to multiple different underlying cardiac and even pulmonary pathologies. One pulmonary pathology that requires careful review of an ECG is an acute pulmonary embolism with or without acute cor pulmonale. CASE PRESENTATION: 74-year-old Caucasian female with history of morbid obesity, recent Roux-en-Y gastric bypass, hypertension, hypothyroidism, COPD on 2L oxygen presented with anxiety, exertional dyspnea and dizziness with activity. Her vital signs were significant for an elevated blood pressure, saturating well on room air. On physical examination, she was anxious with mildly labored breathing, otherwise, normal lung sounds. Her electrocardiogram (ECG) showed T-wave inversions (TWI) in lead III. Her laboratory examination showed a peak troponin level of 0.38, brain natriuretic peptide level 587. A computed tomography chest angiogram confirmed a large saddle pulmonary embolus extending into both pulmonary arteries and multiple segmental and subsegmental branches. A transthoracic echocardiogram showed severely dilation and dysfunction of the right ventricle with flattening of interventricular septum and mild pulmonary hypertension. Lower extremity venous dopplers showed occlusion of left popliteal vein. She was managed with a heparin drip as she remained hemodynamically stable. She had evolving ECG changes with deepening of the TWI in lead III and extending to V1, V2 and all precordial leads Her presentation is consistent with submassive pulmonary embolism. Given careful consideration of her risks and benefits, we elected to continue anticoagulation rather than consider thrombolysis. She was discharged home on oral apixaban. DISCUSSION: T-wave inversions can be noticed in many life threatening medical conditions that include acute coronary syndrome, acute pulmonary embolism (APE), takotsubo cardiomyopathy or can simply represent repolarization abnormalities related to left ventricular hypertrophy. T-wave inversions that are noticed simultaneously in lead III and septal leads, V1, V2, V3 should raise suspicion for acute pulmonary embolism. CONCLUSIONS: Simultaneous T wave inversions in the inferior (II, III, aVF) and right precordial leads (V1-4) is the most specific finding in favor of PE, with reported specificities of up to 99% in one study[1]. Studies have suggested that severe ischemia of the right ventricle may result from an acute right ventricular pressure overload, impaired coronary blood flow and hypoxia caused by APE, possibly leading to negative T waves. Negative T waves are thought to move towards the left that is from lead V1 to V6 in the precordial leads with increasing severity of right heart failure due to limited pericardial expansion. Reference #1: Kosuge M, Ebina T, Hibi K, et al. Differences in negative T waves among acute coronary syndrome, acute pulmonary embolism, and Takotsubo cardiomyopathy. Eur Heart J Acute Cardiovasc Care. 2012;1(4):349-57. Reference #2: Levis JT. ECG Diagnosis: Pulmonary Embolism. Perm J. 2011;15(4):75. DISCLOSURES: No relevant relationships by Fnu Abhishek, source=Web Response No relevant relationships by Navneet Kaur, source=Web Response No relevant relationships by Sowjanya Yenigalla, source=Web Response