Nigerian Journal of Cardiology

CASE REPORT
Year
: 2021  |  Volume : 18  |  Issue : 1  |  Page : 28--30

Rare but not forgotten: Case series of pulmonary embolism with S1Q3T3 pattern


Bui Khiong Chung1, Zhun Foo Tan2,  
1 Department of Cardiology, Sarawak Heart Centre, Kota Samarahan, Malaysia
2 Department of Medicine, Sarawak General Hospital, Ministry of Health, Kuching, Sarawak, Malaysia

Correspondence Address:
Dr. Bui Khiong Chung
Department of Cardiology, Sarawak Heart Centre, Kota Samarahan, Ministry of Health, Kuching
Malaysia

Abstract

Pulmonary embolism (PE) is a common acute cardiovascular disorder. The most common electrocardiograph (ECG) finding in PE is sinus tachycardia. However, the S1Q3T3 pattern of acute cor pulmonale also called McGinn-White sign is classic. We report three cases of a 48-year-old man, 41-year-old woman, and a 66-year-old woman diagnosed with PE with the ECG findings of S1Q3T3 pattern. In conclusion, recognizing these ECG findings could prompt clinicians to consider PE and lead to earlier diagnosis.



How to cite this article:
Chung BK, Tan ZF. Rare but not forgotten: Case series of pulmonary embolism with S1Q3T3 pattern.Nig J Cardiol 2021;18:28-30


How to cite this URL:
Chung BK, Tan ZF. Rare but not forgotten: Case series of pulmonary embolism with S1Q3T3 pattern. Nig J Cardiol [serial online] 2021 [cited 2022 Oct 4 ];18:28-30
Available from: https://www.nigjcardiol.org/text.asp?2021/18/1/28/353683


Full Text



 Introduction



Pulmonary embolism (PE) is a common acute cardiovascular disorder. The most common electrocardiograph (ECG) finding in PE is sinus tachycardia. However, the S1Q3T3 pattern of acute cor pulmonale also called McGinn-White sign is classic.[1] We report three cases of PE with the S1Q3T3” pattern.

 Case Report



Our first patient is a 48 year old man presented with shortness of breath for 3 days associated with chest discomfort and palpitations. This patient had recent right tibia plateau fracture, since then he is using wheelchair and immobilize make him at risk of deep vein thrombosis and pulmonary embolism. On examination, his respiratory rate (RR) was 30 breaths per minute (bpm), on nonrebreather mask, and lungs basal crepitation was heard. His ECG [Figure 1] shows sinus tachycardia and S1Q3T3. Due to the history and ECG suggestive of PE, there for perform CTPA [Figure 2] which confirm PE. He required noninvasive ventilation in the intensive care unit (ICU). He was given anticoagulant and discharged well. Second patient, 41-year-old woman para 3 was on oral contraceptive pills presented with shortness of breath 3 days associated with reduced effort tolerance, orthopnea, and pleuritic chest pain. On examination, her RR was 40 bpm with oxygen saturation (SpO2) 91%–92%. Her lungs were clear. Her echocardiography (ECHO) showed the right ventricle dilated with D-sign and McConnell's sign. Her ECG [Figure 3] showed S1Q3T3 pattern. She proceeded with CTPA [Figure 4] which showed PE at distal both pulmonary arteries extending into segmental branches. She received streptokinase and anticoagulant. She was switch to an intrauterine contraceptive device and discharged well. Last patient, a 66-year-old woman with hypertension and diabetes mellitus was returning from Mecca after 16 h flight. Since then, she felt shortness of breath and had a presyncopal attack. Her symptoms worsened and brought her to the hospital. On examination, her SPO2 was 88% under nasal cannula, RR was 24 bpm, and lungs were clear. Her ECG [Figure 5] showed sinus tachycardia with S1Q3T3. Her ECHO showed right ventricular dilated with D-sign and McConnell's sign. Her CTPA [Figure 6] showed extensive PE in bilateral main pulmonary arteries involving all segments. She was given anticoagulant in ICU and subsequently discharged well.{Figure 1}{Figure 2}{Figure 3}{Figure 4}{Figure 5}{Figure 6}

 Discussion



PE is a common acute cardiovascular disorder with high mortality rates. Diagnosis could be difficult based on the assessment of clinical likelihood, electrocardiography (ECG), chest X-ray, D-dimer levels, cardiac enzyme, blood gases, and need to be confirmed by computer tomography of pulmonary angiography.

Early recognition of a PE is crucial because of the high associated mortality and morbidity, which may be prevented with early treatment. Failure to diagnose PE is a serious management error since 30% of untreated patients die, whereas only 8% succumb with effective therapy.[2] The symptoms associated with PE are nonspecific, such as chest pain and shortness of breath. These symptoms are the common visits to emergency departments (ED), thus cause diagnostic challenges to all who practice emergency medicine. Although no exact epidemiological data, the incidence of PE is estimated to be approximately 60–70/100,000 of the general population.[3]

An ECG is an integral part of the initial evaluation of patients with suspected PE. The most common abnormalities observed in patients with PE evaluated in the ED, according to a retrospective cohort review evaluating the ECG results of 49 ED patients with PE and 49 controls, were sinus tachycardia (18.8% vs. 11.8%), incomplete right bundle branch block (2% vs. 0.0%), complete right bundle branch block (4.2% vs. 6.0%), and S1Q3T3 pattern (2.1% vs. 0%).[4] Although S1Q3T3 is rare, it helps clinicians to consider PE and lead to early diagnosis.

Massive PE can cause a sudden dilatation of the right heart.[5] S1Q3T3 was first described in 1935 in JAMA by Drs. McGinn and White are ECG changes of large S wave in Lead I, Q wave in Lead III, and inverted T wave in Lead III which indicate acute right heart strain.[1] This pattern only occurs in about 4% of people with PEs.[6]

Ferrari et al.[7] found that this pattern had a sensitivity of 54% and a specificity of 62%. Due to the time-sensitive nature of diagnosis and appropriate treatment, the clinical evidence of the acute right heart strain especially S1Q3T3 ECG changes should raise a high suspicion of the diagnosis of PE.

 Conclusion



Recognizing these ECG findings could prompt clinicians to consider PE and lead to earlier diagnosis, therefore prevent delayed treatment and mortalities.

Acknowledgments

We would like to thank the Director General of Health Malaysia for his permission to publish this article. The authors thank the staff of Sarawak General Hospital involved in the management of this patient.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

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3Oger E. Incidence of venous thromboembolism in a community-based study in western France. Thromb Haemost 2000;83:657-60.
4Richman PB, Loutfi H, Lester SJ, Cambell P, Matthews J, Friese J, et al. Electrocardiographic findings in emergency department patients with pulmonary embolism. J Emerg Med 2004;27:121-6.
5Riedel M. Acute pulmonary embolism 1: Pathophysiology, clinical presentation, and diagnosis. Heart 2001;85:229-40.
6Thomson D, Kourounis G, Trenear R, Messow CM, Hrobar P, Mackay A, et al. ECG in suspected pulmonary embolism. Postgrad Med J 2019;95:12-7.
7Ferrari E, Imbert A, Chevalier T, Mihoubi A, Morand P, Baudouy M. The ECG in pulmonary embolism. Predictive value of negative T waves in precordial leads-80 case reports. Chest 1997;111:537-43.