Uncommon electrocardiographic changes corresponding to symptoms during recurrent pulmonary embolism as documented by computed tomography scans

Abstract

Summary: Electocardiographic (ECG) findings of pulmonary embolism (PE) include S I Q~T~ pattern, right bundlebranch block, right-axis deviation, and T-wave inversion in medial precordial leads. We report other uncommon ECG changes associated with various symptoms during recurrent PE as documented by computed tomography (CT) scans in a single patient. An 83-year-old woman was admitted with PE secondary to deep venous thrombosis in the left leg. During episodes of chest pain. ECG showed QTc prolongation (480 Ins) with new T-wave inversion in leads 111, aVF, and VI-V~, and ST-segment depression in leads VS-v6. Despite adequate anticoagulant therapy, recurrent episodes of PE occurred in the hospital. When the patient experienced sudden chest tightness, ECG showed a new S-wave notch in lead V I and clockwise rotation with sinus tachycardia. She also experienced transient syncope with hypotension. At this time, ECG showed transient atrioventricularjunctional rhythm followed by sinus arrest. and CT scan showed a new massive embolus in the main pulmonary trunk with right ventricular dilatation, as demonstrated by echocardiography. The mechanism responsible for QTc prolongation with ST-T changes, the S-wave notch in lead V I with clockwise rotation, or atrioventricular junctional rhythm with sinus arrest during PE may be associated with myocardial ischemia, acute right ventricular overload, or vagal retlex, respectively.

Correlation Between ST-Segment Elevation and Negative T Waves in the Precordial Leads in Acute Pulmonary Embolism: Insights into Serial Electrocardiogram Changes

“…Although ischemic ST‐segment deviation in APE can mimic acute coronary syndrome, ECG changes indicating RVS are helpful to aid in the diagnosis of APE. The ECG parameters of RVS include SI–QIII/SI–QIII–TIII, notched S wave in lead V 1 , RBBB, or Qr sign in lead V 1 …”

ECG-Gated 64-MDCT Angiography in the Differential Diagnosis of Acute Chest Pain

“…Moreover, patients with type A dissection may have ECG changes caused by modulation of coronary flow [19]. There also have been reports of uncommon ECG changes corresponding to symptoms during recurrent pulmonary embolism [20].…”

Electrocardiogram Patterns during Hemodynamic Instability in Patients with Acute Pulmonary Embolism

“…11,12 Notched S wave in lead V 1 is also a common phenomenon in patients with APE 12 and may be associated with acute RV strain. 13,14 Our group has analyzed the QRS morphology in leads V 3 R-V 5 R in 15 adults/senior individuals with notched S wave in lead V 1 . 15 The majority (13 in 15) showed triphasic QRS morphology with final R' wave in their QRS complexes in leads V 3 R-V 5 R. This QRS morphology in association with a notched S wave in lead V 1 is suggestive of the possibility of concealed incomplete or complete RBBB.…”