EKG of the Week 2018 7-8

A 72 y/o female with history of a-fib, MI, complains of chest pressure, onset at rest, non-radiating, associated with SOB. The pain was worsened by taking a deep breath. There was no tearing sensation and no back pain. She had no recent travel, immobilization or surgery.

Her EKG is below.

2018 7-8.jpg

1.     What does the EKG demonstrate?

2.     What is the differential diagnosis for this EKG pattern?

3.     How would you work up this patient?

 

ANSWER:

The EKG shows a-fib with 2 PVC’s and T wave inversions most pronounced in leads V2-V4.

This EKG pattern of T wave inversions in the anteroseptal leads can be seen in anterior wall ischemia, pulmonary embolism, aortic dissection, and intracranial hemorrhage.

Our patient received cardiac enzymes and a D-dimer. Tn was 0.06. D-dimer was 1173. CT showed Right main pulmonary artery embolism extending to right-sided segmental and subsegmental branches.

 

T wave inversions in the anteroseptal leads is abnormal and can be seen in several disease processes. Putting this finding in the context of the patient’s symptoms is very important. For example, if this is seen in a patient with head trauma, it is likely due to intracranial hemorrhage.

Our patient presented with chest pain. She had a previous MI. However, she said this pain was exacerbated by breathing. When asked, she also said this pain was different then her previous MI pain. That prompted the concern for pulmonary embolism which was confirmed by CT.

This patient actually had a chest CT two weeks prior which was negative for PE.

Several EKG patterns have been described in pulmonary embolism including sinus tachycardia, S1Q3T3, S1S2S3, incomplete or complete right bundle branch block, and T wave inversions V1-V4.

Remember to consider a broad differential in patients with chest pain and in patients with anteroseptal T wave inversions.