Chan, WK

Lau, CP

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Title ECG Round: A lady with dyspnoeaAuthor(s) Chan, WK; Lau, CPCitation Hong Kong Practitioner, 1998, v. 20 n. 4, p. 212-214Issued Date 1998URL http://hdl.handle.net/10722/45050Rights Creative Commons: Attribution 3.0 Hong Kong LicenseA Lady With DyspnoeaClinical History:This 61-year-old lady presented with sudden onset of dyspnoea and the following ECG was obtained (Figure 1).Figure 1Question 1: What might be the underlying cause of the ECG abnormalities?A. Acute pericarditisB. Asthmatic attackC. HyperventilationD. Pulmonary embolismThis ECG Round was prepared by: Dr W K ChanDepartment of Medicine & GeriatricsUnited Christian HospitalProfessor C P LauDepartment of MedicineThe University of Hong KongAddress for correspondence: Dr Wai-kwong Chan, Consultant, Department of Medicine & Geriatrics, United Christian Hospital, Kwun Tong, Kowloon.212Hong Kong Practitioner 20 (4) April 1998Answer : D. Pulmonary embolismThe ECG in Figure 1 shows sinus rhythm (rate86/min), S wave in lead I, small Q wave and T waveinversion in lead III and aVF. There were also T waveinversion in leads V1 to V4. These ECG abnormalities,together with the complaint of sudden onset dyspnoea, arehighly suggestive of the diagnosis of acute pulmonaryembolism. In fact, the ECG is most helpful in evaluatingpat ients who have mass ive p u l m o n a r y embolismcomplicated by acute right heart strain.1 In these patients,ECG often demonstrates a new S1Q3T3 pattern, a newincomplete right bundle branch block, or signs of rightventricular ischaemia. The ECG is usually not helpful inpatients with submissive pulmonary embolism.It is very important to have high index of suspicionin d iagnosing p u l m o n a r y embolism as the c l in icalpresentation can be very variable and initial investigationssuch as ECG and chest x-ray may not be very helpful.Ventilation / perfusion lung scans are frequently performedfor diagnosing pulmonary embolism, though pulmonaryangiography is the most accurate test and regarded as thegold standard for the diagnosis. Contrast-enhanced helicalCT scan of thorax is also useful in the diagnosis ofpulmonary embolism involving the main trunks. It has theadvantage of being non-invasive and can be performed asan emergency investigation.This patient was tachypnoeic and in type I respiratoryfai lure despite 50% of inspired oxygen. An urgentcontrast-enhanced helical CT scan of thorax confirmed thediagnosis of massive pulmonary embolism involving theright and left main pulmonary trunk.Question 2: Figure 2 was the ECG of the same patientobtained 4 days later. What treatmentdid the patient have?A. Thrombolytic therapyB. AspirinC. MorphineD. WarfarinAnswer: A. Thrombolytic therapyThe options of treatment of pulmonary embolisminclude heparin, thrombolyt ic therapy and surgery(pulmonary embolectomy). For patients with massivepulmonary embolism and continuing hypoxaemia whilereceiving high fractions of inspired oxygen, intravenousthrombolytic therapy is by far the most extensivelyinvestigated option and the most frequently used optionof intervention.2 In a recent study of 1001 consecutivepatients with acute major pulmonary embolism from 204centres, thrombolytic agents were given to 48% of them,often despi te the presence of c o n t r a i n d i c a t i o n s . 3Thrombolytic therapy, in general, is quite safe. Our localexperience showed that around 10% of patients receivingthrombolytic therapy had bleeding complication, mostlymild bleeding in the gum or around vascular puncturesites.4In view of this lady's massive pulmonary embolisminvolving both right and left main pulmonary arteries, andcontinuing hypoxaemia despite high inspired oxygenconcentration, she was given intravenous thrombolytictherapy. A few hours after the treatment, her tachypnoearesolved and her oxygen saturation was well-maintainedwith low fractions of inspired oxygen. Follow-up contrast-enhanced helical CT scan of thorax one day later revealedthat the thrombus in right main pulmonary artery haddecreased in size and the thrombus in left main pulmonaryartery resolved completely. Comparing to the ECG beforethrombolytic therapy (Figure 1), ECG after treatment(Figure 2) showed decreased amplitude of S wave in leadI, no T wave inversion in lead III or aVF, and decreasedT wave inversion in leads V1 to V3. A haematomadeveloped around her radial artery puncture site andsubsided gradually upon conservative treatment. She wasotherwise stable and subsequently discharged home. •213ECG RoundNDFigure 2References1. Alpert JS, Dalen JE. Pulmonary embolism. In : Schlant RC, AlexanderRW editors. Hurst's The Heart, E igh th E d i t i o n . M c G r a w - H i l lCompanies, International Edition I994;ppl88l .2. Stein PD. Diagnosis and management of pulmonary embolism. CurrentOpinion in Cardiology 1996;11:543-549.3. Kasper W, Konstantinides S, Geibel A, et al. Management strategiesand determinants of outcome in acute major pulmonary embolism: resultsof a multicentre registry. J Am Coll Cardiol 1997:30:1165-1171.4. Chan WK, Chiu A, Yue CS. Prevalence of various complications ofth romboly t ic therapy in pa t i en t s w i t h acute myocardial infarct ion:experience in a local regional hospital. J HK Coll Cardiol 1996;4:77-80.214

ECG Round: A lady with dyspnoea

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ECG Round: A lady with dyspnoea

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