ECG Challenge: Leg Swelling, Short of Breath

September 5, 2017

A 51-year-old man is seen in ED for progressive dyspnea, near syncope on exertion, bilateral edema. What does the tracing tell you?

History: A 51-year-old man with a history of chronic methamphetamine abuse presents to the emergency department with leg swelling, dyspnea, and near-syncope with exertion, symptoms that have been getting progressively worse for about two weeks.  He denies fever, cough, chest pain, or other complaints. He is otherwise healthy.

Exam: Vital signs are normal except for a pulse of 110 beats/min.  His lungs are clear and his heart is tachycardic without murmurs. His legs have 1-2+ bilateral symmetric pitting edema. The rest of the physical exam is normal.

Initial concern(s): Congestive heart failure (CHF), pulmonary embolism (PE), pneumonia.

Testing: Chest x-ray, duplex ultrasound of the legs, and CT angiography chest are negative for pneumonia, DVT, and PE; ECG tracing is shown below.

What's your ECG read?

Please click here for answer and discussion.

 

 

Answer: Cor pulmonale

The ECG shows sinus tachycardia, a right bundle branch block, right atrial enlargement (P-pulmonale), right axis deviation, and possible right ventricular hypertrophy, all consistent with cor pulmonale.  The next day an echo showed severe pulmonary hypertension. The cause was determined to be methamphetamine abuse.

Discussion

Cor pulmonale is right sided CHF, usually caused by obstructive lung disease, which can also be caused by pulmonary hypertension. Symptoms typically include dyspnea on exertion, fatigue, and exertional syncope.  Unlike left sided CHF, examination shows clear lungs. ECG findings are the result of hypertrophy of both the right ventricle and right atrium; these are listed in the tables below.

The diagnosis of cor pulmonale or pulmonary HTN is confirmed by echocardiogram. Treatment depends on severity. Initial emphasis is on control of causative factors or diseases, but in severe cases a variety of medications may be used. See second chart below for medications. For this patient abstinence from methamphetamine abuse was the key component of therapy.

 

DefinitionRight-sided heart disease not from left-sided CHF but from lung dz or pulmonary HTN
ClinicalDOE, fatigue, exertional syncope. May have murmur, JVD, edema…

 

Symptoms Dyspnea, angina, syncope in advanced disease.
Exam:Narrow split S2, RV hypertrophy, right sided CHF, tricuspid regurge
Tests:EKG: RBBB, RAD, RVH, RAE (P-pulmonale: P-wave >2.5mm tall in lead II).
 CXR: large pulmonary artery.
 Echo: dilated RV & pulmonary artery
Causes: Hypoxia, chronic lung dz, drugs, cirrhosis, chronic PE’s, scleroderma/SLE, cardiac shunt Drugs: Methamphetamine, cocaine, Fen-Phen
Rx-acute:100% O2, correct acidosis & fluid status  Drips: dobutamine, milrinone
Rx-chronic:  O2, Flolan, prostacycline, digoxin, sildenafil, bosentan, warfarin, nifedipine, lung transplant

   
For addtional details, click on image below.