SHM Converge Scientific Abstract ePoster Gallery-When a Pulmonary Embolus Hides in an Electrocardiogram

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This case highlights that pulmonary embolism (PE) can present with subtle or atypical findings, even without classic symptoms such as dyspnea, hypoxia, tachycardia, or tachypnea. An 81-year-old man with hypertension came to the emergency department with one week of dry cough, fatigue, and pleuritic chest discomfort. He had a positive COVID-19 test, elevated BNP and troponin, and dynamic ECG changes, but his vital signs were otherwise normal and his chest x-ray was unremarkable.<br /><br />Over six hours, serial ECGs showed evolving T-wave abnormalities, especially in leads III and V2-3. Because of the pleuritic chest pain and rising cardiac biomarkers, a CT angiogram was obtained and revealed large bilateral pulmonary emboli with evidence of right heart strain, including a right ventricular/left ventricular ratio of 1.5 and septal straightening. Echocardiography also suggested elevated right-sided pressures. He was treated with anticoagulation and underwent mechanical thrombectomy due to the large clot burden and concern for heart strain.<br /><br />The report emphasizes that T-wave inversions in leads III and V1-V2 are strongly associated with PE, and the combination of these findings has been reported to have high sensitivity and specificity. In retrospective studies, ECG changes are common in newly diagnosed PE, with T-wave inversion and flattening among the most frequent patterns, while the classic S1Q3T3 pattern is uncommon.<br /><br />The main takeaway is that PE should remain on the differential when inferior and anterior T-wave inversions or flattening appear, even if the patient lacks typical respiratory signs or has an alternative explanation such as COVID-19.

Asset Subtitle

Esther Y. Hsiang

Meta Tag

Author List Esther Y. Hsiang, Sergio Torres, Tianyu Chen

Category Clinical Vignettes

Concept Pulmonary Embolism

Concept Electrocardiogram

Concept T-Wave Change

Concept Cardiac Biomarker

Concept Pleuritic Chest Pain

Distinguished Non-Finalist

Presenter Organization University of California San Francisco

Presenting Author Esther Y. Hsiang

Track Adult

Keywords

pulmonary embolism

T-wave inversion

ECG changes

COVID-19

right heart strain

CT angiogram

pleuritic chest pain

troponin elevation

mechanical thrombectomy

inferior and anterior leads

Pulmonary Embolism

Electrocardiogram

T-Wave Change

Cardiac Biomarker

Pleuritic Chest Pain