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QT Interval Abnormalities with Pulmonary Emboli

      To the Editor:
      I read with interest the report “Telltale T Waves” by Kondamudi et al
      • Kondamudi N.
      • Ali S.R.
      • Khera A.
      Telltale T waves.
      in the February 2019 issue of The American Journal of Medicine. While I take no issue with the findings and points discussed, I believe at least 2 items of importance received no attention but should have. First, marked and diffuse T-wave inversion in association with pulmonary emboli have been reported previously.
      • Punukollu G.
      • Gowda R.M.
      • Khan I.A.
      • Wilbur S.L.
      • Vasavada B.C.
      • Sacchi T.J.
      QT prolongation with global T-wave inversion: a novel ECG finding in acute pulmonary embolism.
      • Liu C.Y.
      Acute pulmonary embolism as the cause of global T wave inversion and QT prolongation. A case report.
      Given Kondamudi et al’s
      • Kondamudi N.
      • Ali S.R.
      • Khera A.
      Telltale T waves.
      focus on the T-wave abnormalities in this patient, I am surprised no references to this point were mentioned. Second, and most striking: In the presenting electrocardiogram (Figure 1 in Kondamudi et al
      • Kondamudi N.
      • Ali S.R.
      • Khera A.
      Telltale T waves.
      ), the QT interval was significantly prolonged. To my eye, the QT as shown is about 480 ms with an R-R interval about 870 ms, giving a corrected QT in excess of 500 ms. The T peak to T end interval in lead V1 was also somewhat long at about 80 ms. Prolonged QT intervals in the setting of acute pulmonary embolism have been reported repeatedly in the literature, with longest QT intervals, greatest QT dispersion, and longer T peak to T end intervals being possibly associated with worse outcomes.
      • Gowda R.M.
      • Vasavada B.C.
      • Khan I.A.
      Prolonged QT interval in acute pulmonary embolism.
      • Ermis N.
      • Ermis H.
      • Sen N.
      • Kepez A.
      • Cuglan B.
      QT dispersion in patients with pulmonary embolism.
      • Akgüllü C.
      • Ömürlü I.K.
      • Eryilmaz U.
      • et al.
      Predictors of early death in patients with acute pulmonary embolism.
      • Onur S.T.
      • Emet S.
      • Surmen S.
      • et al.
      A novel parameter for the diagnosis of acute pulmonary embolism: the T-wave peak-to-end interval.
      • Bonnemeier H.
      • Mauser W.
      • Krauss T.
      • Schunkert H.
      Significant QT interval prolongation in pulmonary embolism – evidence for mechanoelectrical feedback.
      Because these abnormalities have been reversible in pulmonary embolism patients who have survived, it is of no surprise that the prolonged QT interval in Kondamudi’s report resolved as the T wave abnormalities resolved (Figure 2 in Kondamudi et al
      • Kondamudi N.
      • Ali S.R.
      • Khera A.
      Telltale T waves.
      ). In my 40-year experience of caring for patients, I have also seen marked QT prolongation occur in the setting of severe pain, almost certainly an autonomic nervous system-mediated phenomenon, but pain was not cited in the presentation of the patient in this report. Because pulmonary embolism is among the causes of acquired QT prolongation and because QT abnormalities may be of note prognostically in pulmonary embolism, they should be noted on the electrocardiogram in patients where pulmonary emboli are being considered.

      References

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        • Ali S.R.
        • Khera A.
        Telltale T waves.
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        QT dispersion in patients with pulmonary embolism.
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        • Akgüllü C.
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        Predictors of early death in patients with acute pulmonary embolism.
        Am J Emerg Med. 2015; 33: 214-221
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        • et al.
        A novel parameter for the diagnosis of acute pulmonary embolism: the T-wave peak-to-end interval.
        Eur Rev Med Pharmacol Sci. 2016; 20: 1566-1570
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      Linked Article

      • The Reply
        The American Journal of MedicineVol. 133Issue 3
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          We thank Dr Reiffel for his interest in our case description1 and his comments. Indeed, the presence of precordial T-wave inversions in the setting of pulmonary embolism has been described periodically in the literature. The cases described by Dr Reiffel supplement the cases we referenced in our report to reinforce this point. Two theories are often cited as an explanation for this finding. The first is heightened sympathetic tone caused by an autonomic nervous system–mediated response triggered by acute pulmonary embolism.
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