Severe pulmonary embolism and evolution of tracings

Patient

67-year-old man followed for renal neoplasia, hospitalized for sudden onset dyspnea with arterial hypotension (SAP of 80 mmHg); the cardiac ultrasound showed a right ventricular dilatation with pulmonary arterial hypertension; the angioscanner confirmed the diagnosis of bilateral massive pulmonary embolism with right ventricular dilatation; this electrocardiogram was performed at entry;

Trace

Sinus tachycardia (129 bpm); limit PR interval, slightly increased QRS duration (104 ms); SIQ3T3 pattern (negative T-wave in lead III); narrow and shallow Q-wave in the other inferior leads; deviation to the left (between V5 and V6) of the transition (R/S pattern > 1); absence of major repolarization disorders; ventricular extrasystole visible at the beginning of the tracing in precordial leads; Given the presence of shock, hypotension and signs of strain on the right ventricle (acute cor pulmonale), this patient was treated with fibrinolysis to improve the symptomatology (return to systemic arterial pressure > 100 mmHg);

Patient

Tracing recorded 2 hours after the initiation of fibrinolysis; slowing of the sinus rate (117 bpm); decrease in the size of the S wave in lead I; T-wave inversion in V3-V4;

Trace

Tracing recorded 4 hours after the initiation of fibrinolysis; slowing of the sinus rate (108 bpm); disappearance of the S1Q3 pattern;

Trace

Tracing recorded 3 days after fibrinolysis; slowing of the sinus rate (75 bpm); negative T-waves in the lower territory and throughout the precordium; slightly prolonged QT interval (QTc at 460 ms);

Trace

Tracing recorded 10 days later; persistence of major repolarization disorders;

Exergue

Inversion of T-waves in right precordial leads and/or in lead III is the most common of the electrical abnormalities (after sinus tachycardia) observed during pulmonary embolism; the occurrence of peaked and symmetrical T-waves is often later than the changes in the QRS-complex, although persisting longer.