Spurious Pulmonary Embolism

Report:

Sinus rhythm

Reversed arm leads

Left atrial abnormality

Borderline T wave changes.

Comment:

The trace was taken 9 hours after the one in Case 211, presumably because of further chest pain. The interesting thing is, of course, the physician’s report: it confirms earlier suspicion of pulmonary embolism by ignoring the obvious! Psychology triumphs over observation.

The anteroseptal T waves are more prominently inverted than in the previous trace, but the former ECG allows the respiratory swing to be seen quite clearly; it is doubtful that a significant change had occurred. The swing persists in the present trace, in multiple chest leads. Similar swings in V1 are shown in Case 128.

The RAA (now in lead 3) has disappeared, perhaps due to the peaks of the P waves becoming notched. This illustrates why the RAA is better term than P pulmonale: the morphology may be due to vagaries of atrial conduction alone. Another change is the appearance of LAA (manifest as increased PTF in V1). This calls for yet another look at the original (211) trace: its entirely positive P wave in lead V1 indicates incorrect electrode placement - another reason for some difference in T wave appearances between the two traces.

Old cut-and-paste sequential ECG strips, without a good rhythm strip, created some hazards.