This case series documents a 57-year-old female with a history of asthma admitted for episodic dyspnea. Her ECG showed findings suggestive of cor pulmonale from COPD with right heart enlargement. Chest X-ray showed prominent pulmonary arteries. Echocardiogram showed enlarged right atrium and ventricle with moderate-severe tricuspid regurgitation. CT scan revealed filling defects in the pulmonary arteries confirming acute pulmonary embolism, an important cause of morbidity often unsuspected in COPD patients.

1. RJS ECG Case Series
Case 1

2. RJS ECG Case Series
Interpretations
Sinus Tachycardia at 103/min.
Relatively tall P waves in the presence of diffuse low QRS voltage.
Right axis deviation with a S1Q3 pattern associated with diffuse T wave
inversion involving V1-V5.
Slow progression of the R wave in precordial leads (clockwise rotation of
the heart).
Propensity to RBBB in V1 (a subtle finding indicated by an arrow).
Taken together, these findings suggest the diagnosis of COPD with RA
enlargement (cor pulmonale) which is usually accompanied by Pulmonary
hypertension and RV enlargement. Diffuse T wave inversion could be due
to myocardial ischemia, in particular RV. An acute event on top of COPD
can not be excluded.

3. RJS ECG Case Series
Brief Hx and PE Findings
A 57-year-old female with a longstanding hx of
“asthma” was admitted because of episodic dyspnea
that could be worsened with exertion. There were
associated palpitations, bilateral leg weakness, but
no fever, URI symptoms, orthopnea, hemoptysis or
chest pain. Physical findings revealed BT of 36.8℃,
PR 100/min and regular, RR 22/min, and BP 104/59
mmHg. RV lift was palpable, S2 was increased at the
pulmonic area and there was a Gr2/6 systolic murmur
Best heard at the left lower sternal border. The
expiratory phase was slightly prolonged, but there
was no crackles or wheezing.

4. RJS ECG Case Series
• BT= 36.8 ℃ ; PR= 98 beats/min ; RR= 19
times/min ;
• BP= 104 / 59 mmHg

5. Chest X-ray
RJS ECG Case Series
Prominent PA (bilateral)
suggestive of pulmonary
hypertension.
Relatively vertical heart.

6. RJS ECG Case Series
Pertinent Lab Data
Hb PLT WBC MCV Seg Eos Baso Mono Lym
(g/dL) (K/uL) (/uL) (fL) (%) (%) (%) (%) (%)
14.6 155 5670 91 70.9 4.6 0.5 1.4 22.6
BUN Cre K GPT Glucose Myoglobin D-dimer
(mg/dL) (mg/dL) (mmol/L) (IU/L) (mg/dL)
32 1.1 4.3 507 117 55 3770
PT aPTT INR CKMB Troponin-I BNP
(Sec) (Sec) ng/ml
10.5 22.3 1.00 1.5 <0.05 584
ABG- PH : 7.481, pO2: 97.0 %，pO2: 82.6 mm/Hg
pCO2: 28.0 mm/Hg, pCO2: 21.3 mmol/L,
HCO3: 20.4 mmol/L, ABE: -1.6 mmol/L
，

7. RJS ECG Case Series
Echocardiographic Findings
RV
Marked enlargement of RA
and RV. RA
Moderate-to-severe TR.

8. RJS ECG Case Series
McConnell Sign
(Am J Cardiol 78: 469–473, 1996)
The findings of normal wall motion at the apex and abnormal wall motion in the
mid-free wall of RV are indicative of acute pulmonary embolism- sensitivity: 77%;
specificity: 94%; positive predictive value: 71% and negative predictive: 96%.

9. RJS ECG Case Series
Chest CT with contrast
Intraluminal
filling defects
(red arrows) in
bilateral PA.

10. RJS ECG Case Series
Take-Home Message
• Acute PE is an important cause of morbidity
and mortality, but it is often unsuspected and
underdiagnosed, especially when it is
confounded by the presence of COPD and
chronic pulmonary hypertension. In this
case, ECG and chest X-ray findings were of
chronic nature, a high degree of suspicion led
to the order of D-dimer and subsequent chest
CT scan, confirming the diagnosis of PE.

11. RJS ECG Case Series
• Acknolwledgment: The Case was provided by
R1 鄭名翔/VS陳建中 of LiShin Hospital,
• Jhongli, Taoyuan, Taiwan, 03/13/2012.