key: cord-0859922-brsztjf7
authors: Cruz-Utrilla, Alejandro; Segura De la Cal, Teresa; Escribano-Subias, Pilar
title: Giant T Wave Inversion and Dyspnea in the Time of Coronavirus Pandemic
date: 2020-07-01
journal: Circulation
DOI: 10.1161/circulationaha.120.049194
sha: 1fcde0ecda0cdfd785600a0054d6fb12af4b88a8
doc_id: 859922
cord_uid: brsztjf7

nan

The ECG in figure 1 shows right bundle-branch block, right axis deviation, and T wave inversion in right precordial and inferior leads with QT prolongation, findings related to RV strain pattern. Although the diagnostic approach must first discard PE, other causes must be considered. Initially, computed tomography angiography ruled out PE, demonstrating bilateral infiltrates and signs of relevant PH. A second real-time polymerase chain reaction test sample for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was acquired, and was negative. Following medical advice, the patient had stopped taking corticosteroids 2 months previously. Consequently, a plausible explanation could be sarcoidosis reactivation after corticosteroids tapering. Additional work-up included right heart catheterization, cardiac The baseline ECG demonstrates a normal sinus rhythm with heart rate of 90 beats per minute, right bundle-branch block, right axis deviation, and profound inversion of T waves among right precordial (V1-V4) and inferior frontal leads (III-aVF), with a corrected QT (cQT) interval of 489 ms by Bazzet formula. (Figures 4 and 5) . Subsequent transthoracic echocardiography showed signs of significant hemodynamic improvement (eccentricity index of 1.3) and partial restoration of RV diameters. The patient was discharged 10 days later, having lowered Nt-proBNP levels to 567 pg/mL, and without requiring pulmonary vasodilators at that moment. Giant T wave inversion with QT prolongation has been described in a variety of clinical conditions: myocardial ischemia, PE, stress-induced (Takotsubo) cardiomyopathy, nonischemic pulmonary edema, or during acute stroke. COVID-19 has also been associated, mostly related with RV overload in PE or severe respiratory distress cases. Right bundle-branch block and right axis deviation oriented here to PH, however COVID-19 or PE were primarily ruled out. Sarcoidosis-induced PH is a rare and severe entity with multiple causes; the progression of sarcoidosis lung involvement is the most frequent. Other causes have been described, such as granulomatous invasion of pulmonary vessels or extrinsic pulmonary vasculature compression by lymphatic nodes. Treatment thus varies according to the causative mechanism. Immunosuppressive treatment and pulmonary vasodilators are common options. 1 It is well known that frontal plane QRS complex mean electric axis can be useful to follow RV widening. 2 Also, as suggested in rodent models of PH with RV hypertrophy, cQT prolongation in surface ECG could be related with ionic remodeling, and restoration of the oxidative glucose metabolism can normalize cQT interval. 3 Certainly, in this case, corticosteroids along with diuretics and oxygen therapy ameliorated RV hemodynamics and possibly RV-cell metabolism. Moreover, this ECG challenge enlightens how useful the assessment of ECG changes could be during PH treatment. 

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The authors acknowledge Ana Pérez and Ana Lareo for their help during patient hospitalization and for the manuscript editing.

None.

There is a normalization of the cQT interval and subtle changes of T wave in precordial and inferior leads.