A 40-ish-year-old man with a history of asthma presented to the ED with months of gradually worsening leg edema and dyspnea on exertion that he said had become really annoying over the previous five days, each day worse than the last. He had no syncope, palpitations, chest pain, fever, cough, or other complaints.
His vital signs were normal, but his exam was notable for no wheezing or rales but bilateral symmetric leg edema. Four to five small scabs were seen on his neck and forearms; a few looked relatively fresh.
The initial differential diagnosis included congestive heart failure, pulmonary embolism, acute coronary syndrome, and cor pulmonale.
The computer read the ECG as normal sinus rhythm, possible left atrial enlargement, incomplete right bundle branch block, not able to rule out inferior infarct, age undetermined, and T wave abnormality concerning for anterolateral ischemia. Do you agree with the computer?
The computer read was correct but incomplete. The rhythm was normal sinus, but it was almost tachycardic. I am actually in the camp that believes that a normal heart rate is 50-90 bpm rather than 60-100 bpm. The P wave in lead II was a bit wide, which is consistent with left atrial enlargement. There was an RSR in V1-V2 with a QRS of <120 ms consistent with an incomplete right bundle branch block. There were insignificant Q waves in two inferior leads. There was also T wave inversion across the precordial leads. This is the finding that is most likely to be acute. It is consistent with ischemia, but has other potential etiologies, including PE and pulmonary hypertension.
What was not in the computer read was that this ECG highly suggested right ventricular hypertrophy and pulmonary hypertension for several reasons: There was a large deep S wave in lead I, signifying rightward axis, as well as deep wide S waves in the lateral precordial leads. It also showed precordial T inversion and suggestion of right atrial enlargement (a borderline tall P wave in lead II). See more right ventricular hypertrophy examples in Dr. Smith's ECG Blog: https://bit.ly/306xAeq.
The patient's troponin I was 0.05, but did not change on repeat (99% URL <0.030: troponin I immunoassay, Abbott Laboratories). D-dimer was negative. Given the overall picture with the scabs, pulmonary hypertension from methamphetamine was suspected and confirmed.
Pulmonary hypertension is one of the important causes of dyspnea on exertion or shortness of breath, leg edema, and clear lungs. ECG and echo can have findings similar to PE. There are many causes, but methamphetamine abuse is a common one.
Bonus Pearl: Try to avoid intubation in critical patients with pulmonary hypertension because it can worsen the situation.
This post was peer-reviewed by Stephen W. Smith, MD, of Dr. Smith's ECG Blog.
Source: The Emergency Medicine 1-Minute Consult Pocketbook