EKG
RV strain, PE, and cor pulmonale
EKG

RV strain, PE, and cor pulmonale

EKG findings of acute and chronic RV overload — when to suspect what.

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◆Acute RV strain (PE)

  • •Sinus tachycardia (most common)
  • •S1Q3T3 (classic but only ~20%)
  • •T-wave inversions V1–V4
  • •New incomplete or complete RBBB
  • •Right axis deviation

◆Cor pulmonale (chronic RV pressure overload)

  • •P pulmonale: tall (>2.5 mm) peaked P wave in II — RA enlargement
  • •RVH: R/S ratio >1 in V1, right axis deviation
  • •Low voltage in limb leads (COPD with hyperinflation)

◆Diagnosis & management of PE

  • •Low pretest probability (Wells score 0–4) → D-dimer; negative D-dimer rules out
  • •High pretest (Wells >4) or positive D-dimer → CT-PA (V/Q if contrast contraindicated)
  • •Massive PE (hypotension/shock) → systemic thrombolysis (tPA)
  • •Submassive PE (RV strain on echo or CT, +troponin, normotensive) → consider catheter-directed thrombolysis vs anticoagulation alone
  • •Stable PE → DOAC (apixaban or rivaroxaban) for ≥3 mo (longer if unprovoked)

High-yield pearls

  • ◆PE prophylaxis missed → submassive PE post-op is a common board scenario
  • ◆Pregnant patient with suspected PE: V/Q scan preferred over CT-PA (lower radiation to breasts); LMWH for treatment (NO warfarin or DOAC)
  • ◆Echo finding of McConnell's sign (RV free wall akinesia with preserved apex) is highly specific for acute PE
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