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Central chest tightness and breathlessness for two hours

The case

38-year-old man. Central chest tightness and breathlessness for two hours

Smokes fifteen a day. No regular medication and no previous cardiac history. Flew back from a conference in Singapore three days ago. The tightness came on while he was sitting at his desk and has not eased.

On arrival

HR
115
SpO₂ (%)
95
Respiratory rate
22
Temperature (°C)
37
Systolic BP (mmHg)
124
Diastolic BP (mmHg)
78

Stage 1 of 1

Aaron Kettleby is uncomfortable and breathing faster than he should be, but talking in full sentences. The chest is clear, the heart sounds are normal and the calves are soft and non-tender. He is anxious and will not stay still on the trolley. This twelve-lead was recorded three minutes after he arrived.

The tracing for the quiz “Central chest tightness and breathlessness for two hours”.
Twelve-lead recorded at triage, 25 mm/s, 10 mm/mV. Open this tracing in the studio
What do these twelve leads show?

The tracing shows sinus tachycardia at about 115 with T-wave inversion in the anterior leads and inferiorly. The QRS complexes are narrow and there is no ST elevation to suggest an evolving infarct. A Wellens pattern occurs during pain-free intervals with a normal rate, not during active symptoms and tachycardia. Left bundle branch block would produce broad QRS complexes with secondary repolarisation changes, which are not seen here.

A colleague reads the anterior T inversion as a coronary syndrome. Which feature of this tracing argues against that and for acute right heart strain?

In a left anterior descending coronary syndrome, T-wave inversion is confined to the anterior territory. T-wave inversion occurring in both the anterior and inferior leads simultaneously is a recognised pattern of acute right heart strain, because the right ventricle contributes to the electrical forces in both territories. Neither the PR interval nor the ventricular rate alone distinguishes between the two diagnoses, and the frontal axis here is within normal limits.

The baseline wanders markedly through the limb leads. How should that change what you do with this tracing?

The baseline wander affects the limb leads, shifting the whole complex up and down, but the T-wave inversions in the praecordial leads are consistent from beat to beat and can be reliably read. Wander shifts the baseline rather than inverting individual T waves, so it does not create the appearance of inversion where there is none. Discarding the whole tracing would delay a time-critical diagnosis that the praecordial leads have already made.

Diagnosis

Acute pulmonary embolism presenting with anterior T-wave inversion

One of the more specific findings for PE includes negative T waves inferiorly and in V1-V3. That being said, a normal ECG is the most typical finding in all pulmonary embolism cases.

References

  1. Konstantinides SV, Meyer G, Becattini C, et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society. Eur Heart J. 2020;41(4):543-603.
  2. Shopp JD, Stewart LK, Emmett TW, Kline JA. Findings from 12-lead electrocardiography that predict circulatory shock from pulmonary embolism: systematic review and meta-analysis. Acad Emerg Med. 2015;22(10):1127-1137.
Embed 
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Or, where scripts are stripped:

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This tracing was generated, not recorded. It opens in the studio with every dial live.

Open the studio

Discussion

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