ECG Review

Some Pulmonary Diagnoses

By Ken Grauer, MD, Professor, Department of Community Health and Family Medicine, University of Florida. Dr. Grauer is the sole proprietor of KG-EKG Press, and publisher of an ECG pocket brain book.

Scenario

The ECG shown above was obtained from a 54-year-old woman with shortness of breath. What pulmonary findings on ECG might explain her symptoms?

Interpretation

The lead II rhythm strip seen at the bottom of this 12-lead tracing reveals an underlying sinus rhythm with irregularity. Close inspection shows frequent variation in P wave morphology. We interpret this rhythm as sinus with frequent premature atrial contractions. Given the clinical suspicion for pulmonary disease, we view this arrhythmia as part of a spectrum with multifocal atrial tachycardia (MAT) at its extreme. The heart rate here is not fast enough to qualify as tachycardia — but the cause, treatment, and clinical implications of the rhythm for this patient are the same as if the rhythm were MAT. Other findings consistent with pulmonary disease on this tracing include: 1) right axis deviation (RAD); 2) tall, peaked P waves of several different forms in the lead II rhythm strip, suggestive of right atrial abnormality; 3) a tall R>S wave in lead V1; 4) persistent precordial S waves; 5) relatively low voltage diffusely; 6) T wave inversion across much of the precordium consistent with right ventricular "strain." Taken together, the above findings in an adult with dyspnea suggest right ventricular hypertrophy (RVH) with a right ventricular "strain" pattern. Entities to consider include chronic pulmonary disease (emphysema, long-standing asthma) and primary pulmonary hypertension (which is most commonly seen in women the age of this patient). Rapid development of the above ECG picture would suggest acute pulmonary embolism. Admittedly, diffuse precordial T wave inversion as seen here could reflect an ischemic process — but the combination of findings described above is much more suggestive of a pulmonary diagnosis. This degree of RAD, the predominant R>S wave in lead V1, the presence of RV "strain," and the arrhythmia shown above all strongly suggest marked severity of whatever the underlying pulmonary disorder turns out to be.