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Chest Pain and Cardiac Dysrhythmias

A 38-year-old woman presents to the emergency department (ED) with chest pain and mild shortness of breath that began the night before. She was able to sleep without difficulty, but awoke in the morning with persistent pain that worsens with a deep breath. Upon walking up a flight of stairs, she became very short of breath, prompting her ED visit. On physical exam, she was noted to be tachycardic and have left calf pain. She has no past medical history (PMH), but has smoked half pack per day for 15 years and is on an oral contraceptive.

What is the most common electrocardiogram (ECG) finding for this patient’s diagnosis?

a. S1Q3T3 pattern

b. Atrial fibrillation (AF)

c. Right-axis deviation

d. Right bundle-branch block (RBBB)

e. Sinus tachycardia

The answer is e. The patient most likely has a PE originating from a thrombus in her left calf. The diagnosis of PE is usually made with a CTA or less commonly a ventilation-perfusion scan performed in nuclear medicine. The most common ECG abnormalities in the setting of PE are sinus tachycardia and nonspecific ST-T–wave abnormalities. Other ECG abnormalities may be present and suggestive of PE, but the absence of ECG abnormalities has no significant predictive value. Moreover, 25% of patients with proven PE have ECGs that are unchanged from their baseline state.

With a large PE, the right heart becomes strained. Classic ECG findings of right heart strain and acute cor pulmonale are tall, peaked P waves in lead II (P pulmonale), right-axis deviation (c), incomplete or complete right bundle-branch block (d), a S1Q3T3 pattern (a), or AF (b). The finding of S1Q3T3 pattern is nonspecific and insensitive in the absence of clinical suspicion for PE. Unfortunately, only 20% of patients with proven PE have any of these classic ECG abnormalities.

A 38-year-old woman presents to the emergency department (ED) with chest pain and mild shortness of breath that began the night before. She was able to sleep without difficulty, but awoke in the morning with persistent pain that worsens with a deep breath. Upon walking up a flight of stairs, she became very short of breath, prompting her ED visit. On physical exam, she was noted to be tachycardic and have left calf pain. She has no past medical history (PMH), but has smoked half pack per day for 15 years and is on an oral contraceptive.

Which of the following tests is best to confirm the suspected ...

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