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In August 2005, a 54-year-old female was referred to our centre for additional evaluation into the aetiology of recently established severe pulmonary arterial hypertension (PAH). The patient had first experienced exertional dyspnoea six months prior to presentation to the referring cardiologist. There was no history of cardiac or pulmonary disease, but this patient had undergone an extensive cardiac evaluation seven years before, after a single episode of syncope. At that time, the ECG showed a sinus rhythm, a QRS axis of 36°, normal P waves, conduction intervals within normal limits, and inverted T waves in leads II, III, aVF and V1 to V6 (figure 1A). Because of the observed repolarisation abnormalities, a series of additional tests was performed. Apart from severe hyperthyroidism, there were no cardiac or pulmonary abnormalities found at echocardiography (tricuspid and pulmonary valve regurgitation gradients were within normal limits, there was no right atrial or ventricular dilatation, right ventricular hypertrophy, or paradoxical septal bowing), left heart and coronary catheterisation, or pulmonary function tests. At renewed presentation, the ECG now showed a QRS axis of 90°, the R wave in lead V1 measured 6 mm in the absence of an S wave, and there were diffuse repolarisation abnormalities, all in agreement with an increased right heart load (figure 1B).
Figure 1
A. ECG of the patient at first presentation, seven years before the diagnosis of PAH, demonstrated a regular sinus rhythm of 65 beats/min, a QRS axis of 36°, normal P waves, conduction intervals within normal limits, and an inverted T waves in leads II, III, aVF and V1 to V6. In short, there was no reason to suspect an increased right heart load at the time, based on this ECG. B. The ECG recorded at the time of renewed presentation showed a regular sinus rhythm of 84 beats/min, a QRS axis of 90°, the R wave in lead V1 measured 6 mm in the absence of an S wave, and there were diffuse repolarisation abnormalities, all in agreement with an increased right heart load. Given this second ECG, especially with an ECG available from several years before, further investigation regarding an increased right heart load is warranted.
