Fast Facts-Cardiology

November 20, 2006

Welcome to Fast Facts-a new feature of Clinical Correlations.  Look for frequent posts summarizing key teaching points from Morning Reports and Noon Conferences from Bellevue, Tisch and the VA.

Bellevue 11/16/08-William Slater M.D.

34 yo female, 4 weeks post-partum, presents with progressive DOE, othopnea, and bilateral pleural effusions on CXR.  Working DDx: Postpartum Cardiomyopathy, PE, Primary Pulmonary HTN TTE with normal EF, right ventricle dilatation, and PAP >50 mmhg..

  • ECG changes due to PE: The classical S1Q3T3 reflects delayed rightward forces (S1) as well as the fact that the inferior wall is shared by both LV and RV so inferior T wave inversions can also come from RV strain as well as LV strain.  We should see changes that occur due to right ventricle obstruction causing delayed forces.  This can be most sensitively seen as late right ward forces in the lateral leads and AVR.  So in the lateral precordial leads (V5,V6) you would see small s waves in the QRS complex.  In AVR you expect to see a second small R waves as well.
  • Atrial dilatation takes longer than ventricular dilatation.  If you see atrial dilation by ECG, CXR, or echocardiographic results, you should suspect that whatever pathologic process taking place is not an acute process  
  • Atrial dilatation is best seen Lead II, and V1. In V1 Right atrial dilation is manifested by a TALLER P wave, while left atrial dilation (due to the depolarization forces moving away from the lead) is seen as a WIDENED P wave.
  • Atrial Septal Defects is heard as an outflow murmur across the pulmonic valve (soft syst murmur at the base, can be confused with just a flow murmur but has a fixed split S2) because of increased right sided flow.

Next Step given normal EF is a work up for pulmonary hypertension.  Chest CT to r/o pulmonary disease or secondary pulm HTN.  Right heart catherization if her symptoms do not improve.