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The Reply

  • Nitin Kondamudi
    Affiliations
    Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Tex

    Division of Cardiology, UT Southwestern Medical Center, Dallas, Tex
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  • Shah R. Ali
    Affiliations
    Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Tex

    Division of Cardiology, UT Southwestern Medical Center, Dallas, Tex
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  • Amit Khera
    Correspondence
    Requests for reprints should be addressed to Amit Khera, MD, MSc, FACC, FAHA, Division of Cardiology, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-8830.
    Affiliations
    Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Tex

    Division of Cardiology, UT Southwestern Medical Center, Dallas, Tex
    Search for articles by this author
      We thank Dr Reiffel for his interest in our case description
      • Kondamudi N
      • Ali
      • Khera SR
      • Telltale A.
      • waves T
      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. The other is myocardial ischemia caused by reduced cardiac output in the setting of acute right ventricular dilatation.
      • Horn H
      • Dack S
      • Friedberg C
      Cardiac sequelae of embolism of the pulmonary artery.
      Although these theories have been postulated, the mechanism remains unclear. Dr Reiffel's observations regarding QT prolongation and the T peak to T end (TpTe) interval are instructive. Taken together, T-wave inversion, QT prolongation, and TpTe interval prolongation all have diagnostic and prognostic implications in the evaluation of pulmonary embolism, as highlighted in this case. Furthermore, these are a few among many electrocardiographic findings that have been associated with pulmonary embolism, including but not limited to ST depression, ST elevation, atrial tachyarrhythmias, peaked p waves, low voltage, QT dispersion, and QRS fragmentation.
      • Digby GC
      • Kukla P
      • Zhan ZQ
      • et al.
      The value of electrocardiographic abnormalities in the prognosis of pulmonary embolism: a consensus paper.
      Given the heterogeneity in the electrocardiographic manifestations of pulmonary embolism, we highlight the importance of careful electrocardiogram analysis in patients in whom the diagnosis of pulmonary embolism is being considered.

      References

        • Kondamudi N
        • Ali
        • Khera SR
        • Telltale A.
        • waves T
        Am J Med. 2019; 132: 187-190
        • Horn H
        • Dack S
        • Friedberg C
        Cardiac sequelae of embolism of the pulmonary artery.
        Arch Intern Med. 1939; 64: 296-321
        • Digby GC
        • Kukla P
        • Zhan ZQ
        • et al.
        The value of electrocardiographic abnormalities in the prognosis of pulmonary embolism: a consensus paper.
        Ann Noninvasive Electrocardiol. 2015; 20: 207-223

      Linked Article

      • QT Interval Abnormalities with Pulmonary Emboli
        The American Journal of MedicineVol. 133Issue 3
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          I read with interest the report “Telltale T Waves” by Kondamudi et al1 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.2,3 Given Kondamudi et al’s1 focus on the T-wave abnormalities in this patient, I am surprised no references to this point were mentioned.
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