Syncope and Flash Pulmonary Edema with T-wave Inversions in V1-V3

A 60 yo with no cardiopulmonary history, felt dizzy, cold and clammy, and then had syncope.  She denied SOB or Chest pain.  Pulse oximetry was 95%.  Lung and heart exams were normal.A bedside echo done by an ultrasound-fellowship-trained EP was recorded as normal.She had an ECG as part of her syncope workup:There is an abnormal Q-wave in lead III (greater than 40 ms in width is abnormal).  There is nonspecific T-wave flattening in in inferior leads and in V2 and V3, and nonspecific T-wave inversion in V4-V6.With the abnormal, but nondiagnostic, ECG, a wider workup was initiated. A troponin I returned elevated at 0.290 ng/mL (normal, less than 0.030).A chest X-ray was obtained:This shows perihilar pulmonary edema.So we have:Syncope, mild flash pulmonary edema, and an elevated troponin with a nondiagnostic ECG.A repeat ECG was obtained:Now there are developing T-wave inversions in V1-V3 and also lead III.This pattern is classic for pulmonary embolism.  Click on this link for a detailed post on the ECG in pulmonary embolism.However, pulmonary edema is very rare in pulmonary embolism.  PE decreases pulmonary artery pressure (an increase is what leads to cardiogenic pulmonary edema).  For this reason, it was assumed that the T-wave inversions are more likely due to LAD ischemia (Developing Wellens' waves), and not due to PE.  This is spite of the fact that the T-wave inversions are atypical for Wellens' waves: pattern A has slight ST el...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs