A 30-something woman with chest pain and h/o pulmonary hypertension due to chronic pulmonary emboli

A 30-something woman with known history of pulmonary hypertension due to chronic pulmonary emboli presented with 12 hours of substernal chest pain.

Here was her ED ECG:

What do you think?

This precordial T-wave inversion is typical of right ventricular hypertrophy (RVH).  However, most other features of RVH are not present.  There is an incomplete RBBB, which does support RVH.  But there is no right axis deviation (axis is however borderline at 83 degrees, nearly vertical.  There is no large R-wave in V1.  However, these findings are not sensitive enough for RVH to rule it out.

The T-wave morphology, along with the known history of pulmonary hypertension, should alert you to look for a previous ECG.

I saw this and thought immediately that this was probably her baseline EKG.  We looked for old ones, and indeed previous ECGs were identical.

The patient ruled out for both PE and MI while in the ED, and could be discharged.  This was her baseline ECG.  Our diagnosis was gastroesophageal reflux.

Here are a couple other cases of RVH:

55 year old woman with chest pain and precordial T-wave Inversions

This one does have right axis deviation and a large R-wave in V1


A 50-something male with Dyspnea

This one also has right axis deviation and a large R-wave in V1

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