Two differential diagnoses for deep T wave inversion V1-V3:



Two differential diagnoses for deep T wave inversion in V1-V3:

-Anterior non-ST-elevation ischemia

-PE

Note: This is different from ST-segment depression in V1-V3, which signifies posterior STEMI

RVH on ECG:

1.Right axis deviation ≥+90º (or close to 90º)

+

2. R>S in V1

Or S>R in V6

Or R≥7 mm in V1

In the absence of right axis deviation, R>S in V1 is not enough to make RVH diagnosis (could be posterior MI, WPW, RBBB, or normal variant)

ECG findings in PE:

|1-Sinus tachycardia is the most common finding. Heart rate may be 80s-90s rather than >100. |

| |

|2-T wave inversion V1-V3 (2nd most common finding in massive or submassive PE) |

| |

|3-Right axis deviation |

|-RVH |

|-RBBB (incomplete or complete) |

|-Right atrial enlargement (P pulmonale) |

|-Deep S in lead I, Q and T-wave inversion in lead III (S1Q3T3) which actually represent right axis deviation with RV hypertrophy |

| |

|4-Atrial arrhythmias: PACs, AF, Aflutter |

These findings are not specific and may be seen in any RV volume or pressure overload state, whether acute or chronic (asthma or COPD exacerbation, pneumonia, PTX ). In the right context however, they are specific for PE. Sinus tachycardia is quite sensitive (>80%), each one of the other criteria is ~10-20% sensitive, the combination of them is ~50% sensitive. Second to sinus tachycardia, T inversion in V1-V3 is the most sensitive finding in massive or submassive PE (85%). When PE is large enough to produce marked hypoxemia or shock, several of those changes are ~ always present, esp. T inversion in V1-V3. A heart rate of 60s or less makes PE highly unlikely.

Thrombolysis should be considered in case of RV overload or PA pressure>40 if bleeding risk is low (Grade 2 recommendation). It should absolutely be used in case of shock (grade 1 recommendation, ACCP).

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