New onset chf?

HPI: The patient is a 66 yo F with PMH CHF (TTE 9/2009 with LVEF 50%, RVSP 42), CAD s/p cath ( no stents), DMII, HLD, HTN, and morbid obesity who presents with a cc of abdominal swelling.  Onset was 3 months prior to presentation with persistent worsening since that time.  She denies any SOB or chest pain/diaphoresis and denies any home O2 use.  She does endorse significant weight gain and lower extremity swelling during the same time period.  Otherwise, ROS is significant for a fall yesterday, reported to be mechanical without LOC.
 
Labs: remarkable for BNP >2000, no prior value.  Troponin 0.01.

EKG:

Interpretation: Normal sinus rhythm.  Rate 76.  Right axis deviation with deep S wave in lead I.  Normal PR, QRS, and QT intervals.  T wave inversions noted in II, III, avF, and all precordial leads. R wave progression which is remarkable for predominantly upgoing QRS in lead V1 with qR complex.  As compared to prior EKG(2009), Afib is not present on current.  All of the above findings are new.
 
Conclusion: The patient was subsequently admitted for new onset CHF.  Following the echocardiogram which demonstrated the above, the patient was gradually diuresed with plans for RHC to further clarify RVSP with the goal of starting pulmonary vasodilator therapy.  RHC was performed 9 days after admission following volume optimization and demonstrated PA 78/36.  Pulmonary vasodilator therapy was initiated and the patient was discharged home on these medications.
 
Teaching Points:
 
This patient’s EKG from admission is very consistent with right ventricular hypertrophy and severe pulmonary hypertension.  This is evidenced by the new right axis deviation.  Further evidence is the qR complex with predominantly upgoing QRS in V1 and T wave inversions inferiorly and in the anterior chest leads.
 
EKG evidence of Pulmonary Hypertension:

• right axis deviation (deep S wave in I)
• qR complex with predominantly upgoing QRS in V1 ("shortevity sign" - Littman)
• signs of RV strain (T-wave inversions in inferior and anterior chest leads)
• In combination, the above findings are very specific indicators of pulmonary hypertension

 
Blyth et. al.  Quantitative estimation of right ventricular hypertrophy using ECG criteria in patients with pulmonary hypertension: A comparison with cardiac MRI.  Pulm Circ.  2011.  470-4.
 
Whitman et al.  Validity of the surface electrocardiogram criteria for right ventricular hypertrophy: the MESA-RV study.  J Am Coll Cardiol. 2014 Feb 25; 63:672-81.
 
Blog by Dr. Jaron Raper