Written by Clay Smith
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What’s your differential diagnosis for this ECG?
Why does this matter?
We find ourselves in the COVID-19 era. This changes the differential diagnosis for several illnesses. This is an important ECG pattern for us to know.
My, what big inverted T waves you have!
This was a case report in JACC, a 21 year old man with sarcoidosis who had tapered steroids over the previous two months. He had 2 weeks of dyspnea on exertion and leg edema. Labs: Nt-proBNP 7737 pg/mL; hs-T-Troponin 24 ng/L (normal <14 ng/L). ECG is below.
What do you see here?
What is your differential diagnosis?
(This is intentional blank space so you can’t see the answer right away.)
Answer: There is a right bundle branch block pattern, pronounced T wave inversions in the early precordial and inferior leads, right axis deviation, and prolonged QTc. This indicates RV strain.
This patient did not have COVID-19, and a CT ruled out PE. He turned out to have worsening pulmonary sarcoidosis and pulmonary hypertension-induced RV remodeling, likely made worse by his recent steroid taper. The point of this ECG is to recognize RV strain. The first consideration should be PE. Once you rule that out, we can take a little more time to figure out the rest.
Source
Giant T Wave Inversion and Dyspnea in the Time of Coronavirus Pandemic. Circulation. 2020 Sep;142(9):906-909. doi: 10.1161/CIRCULATIONAHA.120.049194. Epub 2020 Jul 1.
Open in Read by QxMD
Give me he same patient several years older with a couple of CV risk factors (perhaps not even necessary) and if those deeply inverted T waves in V2 were as significant in V3, I would have called them wellens type B and had the patient sent for cath.
I would have related the rest to LV dysfunction, which is fair
Repeat ECGs show anything interesting?
Dr A Roux
Emerg doc in South Africa
Great point. Wellen’s syndrome has a few features that are distinct. We did this post on it. https://journalfeed.org/article-a-day/2020/can-you-spot-wellens-syndrome