title: Simultaneous T-wave inversions in anterior and inferior leads: an uncommon sign of pulmonary embolism.
abstract: BACKGROUND
  Pulmonary embolism (PE), a major cause of morbidity and mortality, remains an elusive diagnosis. Recently investigators have found a new electrocardiographic (ECG) finding, simultaneous T-wave inversions in the anterior and inferior leads, which may distinguish PE from acute coronary syndrome (ACS).
  
  
  OBJECTIVE
  Our primary objective was to estimate the prevalence of this finding in PE. We also estimate the inter-rater reliability of this finding, its test characteristics, and assess ECG findings traditionally associated with PE.
  
  
  METHODS
  In this unmatched case-control study, we selected electrocardiograms from patients diagnosed with PE, ACS, and non-cardiac chest pain. Two emergency physicians, blinded to diagnoses, reviewed electrocardiograms for explicitly defined ECG findings. We calculated kappa (K) for inter-rater agreement and estimated prevalence differences (PD) for findings in the PE group vs. pooled control groups.
  
  
  RESULTS
  We included 97 patients with PE, 89 with ACS, and 105 with non-cardiac chest pain. A 1-mm T-wave inversion was seen in both III and V(1) in 11/97 (0.113) of patients with PE vs. 9/194 (0.046) controls (PD 0.07 [95% confidence interval (CI) -0.01-+0.14]; K = 0.7). Other criteria for anterior and inferior T-wave inversions were less common in PE (0.04-0.05). Among several other ECG abnormalities tested, only sinus tachycardia (PD 0.20 [95% CI 0.09-0.31]; K = 0.7) and the classic S(I)Q(III)T(III) pattern (PD 0.05 [95% CI -0.01-+0.11]; K = 0.5) statistically distinguished PE and were noted with fair or better inter-rater agreement.
  
  
  CONCLUSIONS
  In our study, simultaneous T-wave inversions in anterior and inferior leads were associated with PE but are seen in only 4-11% of cases.
authors.affiliation: Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA.
authors.forename: Michael D
authors.initials: MD
authors.lastname: Witting
authors.forename: Amal
authors.initials: A
authors.lastname: Mattu
authors.forename: Robert
authors.initials: R
authors.lastname: Rogers
authors.forename: Christian
authors.initials: C
authors.lastname: Halvorson
mesh_terms: D054058:Acute Coronary Syndrome / Q000175:diagnosis* / Q000503:physiopathology*; D000328:Adult; D000368:Aged; D016022:Case-Control Studies; D002637:Chest Pain / Q000503:physiopathology; D003937:Diagnosis, Differential; D004562:Electrocardiography; D006801:Humans; D008875:Middle Aged; D015588:Observer Variation; D011655:Pulmonary Embolism / Q000175:diagnosis* / Q000503:physiopathology*; D016037:Single-Blind Method