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(Circulation. 2000;102:2441.)
© 2000 American Heart Association, Inc.

Images in Cardiovascular Medicine

Acute Pulmonary Embolism

Ravi K. Garg, MD; James Bednarz, BS; Kirk T. Spencer, MD; Roberto M. Lang, MD

From the Division of Cardiology, University of Chicago Medical Center, Department of Medicine, Section of Cardiology, Chicago, Ill.

Correspondence to Roberto M. Lang, MD, University of Chicago Medical Center, 5841 S. Maryland Ave., MC5084, Chicago, IL 60637. E-mail rlang@medicine.bsd.uchicago.edu

A55-year-old man with a history of paroxysmal atrial fibrillation, hypertension, and stroke presented to the emergency room with the acute onset of shortness of breath. He had previously been prescribed warfarin therapy, which was self-discontinued 3 months before admission. A baseline ECG made 6 months before admission showed normal sinus rhythm with a heart rate of 80, an axis of -15°, and nonspecific T-wave abnormalities (Figure 1A).

View larger version (117K): [in this window] [in a new window]   Figure 1. A, Baseline ECG obtained 6 months prior to admission. B, Admission ECG. C, Hospital day 2 ECG, after thrombolytic therapy.

Physical examination at admission showed a respiratory rate of 35, pulse of 130, and blood pressure of 130/90 mm Hg. The heart had a regular rhythm with a normal S₁, loud P₂, 2+ right ventricular (RV) heave, and a 2/6 holosystolic murmur at the left lower sternal border. The left calf was enlarged compared with the right, with increased warmth and tenderness. The ECG on presentation depicted sinus tachycardia with a heart rate of 133, a rightward axis shift, the McGinn and White pattern (S₁Q₃T₃) associated with clockwise rotation of the heart, an incomplete right bundle branch block, and nonspecific ST segment and T-wave abnormalities (Figure 1B). CT of the chest showed multiple bilateral low attenuation filling defects in the lobar and segmental pulmonary arteries, as well as a large fusiform filling defect in the main pulmonary artery bifurcation consistent with pulmonary emboli (Figure 2A). On transthoracic ECG, the RV was severely dilated and dysfunctional . . . [Full Text of this Article]