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(Circulation. 2000;102:2441.)
© 2000 American Heart Association, Inc.
Images in Cardiovascular Medicine |
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
).
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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
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