Acute pulmonary embolism is a disease which is fatal and often easily missed as it may mimic cardiac diseases.
We report two cases of acute PE presenting with ACS. The first case was a 64-year-old female with underlying diabetes mellitus and hypertension. She presented with sudden onset of shortness of breath associated with left sided chest pain, diaphoresis, nausea and vomiting. On examination, she was tachycardic and tachypneic with low oxygen saturation. Chest X-ray revealed blunting of costophremic angle bilaterally. ECG showed STelevation at inferior leads with reciprocal changes. Bedside ECHO was normal. In view of a recent major gynaecological surgery of this patient, D-dimer was done and tested positive. CTPA revealed PE. The second case involved an 81-year-old female with underlying hypertension and history of right hip fracture 3 years ago. She presented with sudden onset of shortness of breath with chest discomfort. Clinically, patient was tachypneic with low oxygen saturation. Respiratory examinations were unremarkable. ECG showed T-inversion in inferior and anterior leads. Cardiac enzymes were not raised. Bedside ECHO revealed dilated right ventricle with hypokinesia. CTPA showed an extensive PE with right lung infarction.
Several ECG changes in PE have been reported with sinus tachycardia being the most common. Even the ‘classic’ S1Q3T3 pattern is found in 20% of patients only. This finding is not specific and not sensitive. We would like to highlight other ECG changes suggestive of myocardial ischemia mimicking PE. ST elevation in the inferior leads are seen in PE have been reported but is extremely rare. Furthermore, simultaneous T-wave inversions in anterior and inferior leads are also found in only 4 – 11% cases of PE.
A high index of suspicion of PE should always be raised in patients with ECG changes suggestive of a myocardial ischemia whom the clinical presentation does not tally with a possible cardiac event.