Case 39: A 39-Year-Old Man with Progressive Exertional Dyspnea
A 39-year-old man with past history of recurrent deep vein thrombosis is presenting with dyspnea on exertion that has been progressive during the last 3 weeks:
- Sinus rhythm, 95/min
- Possible left atrial enlargement
- Right axis deviation
- S1Q3 pattern
- Incomplete right bundle branch block (iRBBB)
- Markedly negative T waves in the chest leads
These findings are supportive of the clinical diagnosis of pulmonary embolism:
S1Q3T3 (S in lead I, Q wave and negative T in lead III), right bundle branch block, right axis deviation, P pulmonale are traditionally mentioned as ECG findings in acute pulmonary embolism but occur in a minority of patients (26% in a study reported by P.D.Stein at al). The ST and T abnormalities are the most frequent findings. The Q wave in the inferior leads may simulate inferior wall infarction.
A spiral CT scan of the chest in this patient showed bilateral pulmonary emboli. The main pulmonary artery and the right cardiac chambers were markedly enlarged. Coagulation studies were positive for anti-cardiolipin antibodies. Doppler studies demonstrated a popliteal thrombus in the right leg and a deep saphenous thrombus in the left leg.
Stein PD, Dalen JE, McIntyre KM, Sasahara AA, Wenger NK, Willis PW 3rd. The electrocardiogram in acute pulmonary embolism. Prog Cardiovasc Dis. 1975 Jan-Feb;17(4):247-57
ECG ID: E519