Rotators Discussion

By Dr. Ahmed Adel This ECG is highly suggestive for acute RV strain. Some may even say pathognomonic. The most important findings are the T wave inversions (TWIs) in leads V1–V3. Given the clinical context & these ECG findings, the main considerations in the ED setting here are ACS vs acute RV strain (the most common cause of which by far being PE). How can we tell them apart? (hint: think inferior vs lateral extension) • RV strain results in TWIs maximally in the right precordial leads (V1-V3) & often extending to the inferior leads (mainly lead III as it reflects the right portion of the inferior wall). • In ACS, the TWIs are not necessarily maximal in V1-V3 & may extend laterally beyond V4-V5, sometimes well into leads I & aVL. The T waves in lead III in such cases are almost always upright. >> This was demonstrated by Kosuge et. al.: in the clinical setting of ACS vs PE & TWIs in at least 2 out of leads V1-V4, 88% of patients with PE have an inverted T wave in lead III, whereas nearly all patients with ACS have an upright T wave in this lead. Note: although sinus tachycardia is the most common ECG abnormality seen in PE, it is present in less than half of PE cases. Its absence alone by no means excludes PE. Over-reliance on sinus tachycardia can therefore lead to missed PE diagnoses! Take-home message: In the appropriate clinical setting, the “inferior + anterior” T-wave inversion pattern is highly specific (99%) for PE.