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McGinn-White pattern

      1. Case description

      A 52-year-old man presented to the emergency department with a 2-month history of worsening dyspnea which intensified during the last 3 days. On physical examination, his blood pressure was 119/68 mm Hg, his pulse rate was 99 beats per minute, and his respiratory rate was normal. An electrocardiographic study (Fig. 1A) and computed tomographic (CT) angiography of his chest (Fig. 1B) were performed at the time of hospital admission.
      Fig 1
      Fig. 1A Initial electrocardiogram on presentation showing the S1Q3T3 sign (McGinn-White pattern; arrows); B Computed tomography scan of chest with contrast, cross sectional image, displaying massive filling defects in main pulmonary arteries (arrows).
      What is the diagnosis?

      2. Discussion section

      2.1 Diagnosis

      McGinn-White pattern caused by bilateral pulmonary embolism
      Evaluation by means of 12-lead electrocardiography revealed complete right bundle branch block and signs of right ventricle strain (inverted T waves in leads III, aVF and V1 to V4) and injury (ST elevation in lead aVR and ST depression in leads V4 to V6). S waves in lead I and Q and negative T waves in lead III were also evident (S1Q3T3 pattern) (Fig. 1A, arrows; Q waves amplitude, >1.5 mm). D-dimer was elevated at 1998 ng/mL (normal range, 0-500) and high-sensitivity troponin I was elevated at 419 ng/L (normal range, ≤40). Chest CT demonstrated large clots in both main pulmonary arteries (Fig. 1B, arrows). Echocardiography showed right ventricular dilatation and systolic dysfunction. He was anticoagulated, had no complications, and was discharged 9 days after admission. At the 4-month follow-up, he remained asymptomatic.
      McGinn and White first described the so-called `S1Q3T3´pattern in 1935 in five patients with acute cor pulmonale due to pulmonary embolism (PE) [
      • McGinn S.
      • White P.D.
      Acute cor pulmonale resulting from pulmonary embolism.
      ]. This classically taught sign has been usually reported in about 24 per cent of PE patients [
      • Shopp J.D.
      • Stewart L.K.
      • Emmett T.W.
      • Kline J.A
      Findings from 12-lead electrocardiography that predict circulatory shock from pulmonary embolism: systematic review and meta-analysis.
      ] and has a high specificity for this entity [
      • Thomson D.
      • Kourounis G.
      • Trenear R.
      • Messow C.M.
      • Hrobar P.
      • Mackay A.
      • Isles C
      ECG in suspected pulmonary embolism.
      ]. In addition, this pattern is associated with increased risk of circulatory shock and in-hospital mortality from PE [
      • Shopp J.D.
      • Stewart L.K.
      • Emmett T.W.
      • Kline J.A
      Findings from 12-lead electrocardiography that predict circulatory shock from pulmonary embolism: systematic review and meta-analysis.
      ,
      • Qaddoura A.
      • Digby G.C.
      • Kabali C.
      • Kukla P.
      • Zhan Z.Q.
      • Baranchuk A.M
      The value of electrocardiography in prognosticating clinical deterioration and mortality in acute pulmonary embolism: a systematic review and meta-analysis.
      ].

      Contributorship

      The implication of each author in the elaboration of the manuscript was as follows:
      Tabled 1
      Miguel F Carrascosa:1-6, 8-11
      Rubén Gómez-Izquierdo:2-4, 6, 8, 10, 11
      Marta Cano Hoz:2-4, 6, 8, 10, 11
      Legend:
      • 1
        Care for the patient
      • 2
        Substantial contribution to study conception and design
      • 3
        Acquisition of data
      • 4
        Analysis and interpretation of data
      • 5
        Drafting of the manuscript
      • 6
        Critical revision of the manuscript for important intellectual content
      • 7
        Statistical analysis
      • 8
        Administrative, technical, or material support
      • 9
        Study supervision
      • 10
        Final approval of the version to be published
      • 11
        Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved

      Declaration of COmpeting Interest

      We declare no competing interests. In this regard and more specifically:
      - There were no funding sources in the writing of the manuscript or the decision to submit it for publication.
      - The authors of the manuscript have not been paid to write this article by a pharmaceutical company or other agency.
      - Miguel F Carrascosa, the corresponding author, had full access to all the data in the study and had final responsibility for the decision to submit for publication.

      References

        • McGinn S.
        • White P.D.
        Acute cor pulmonale resulting from pulmonary embolism.
        JAMA. 1935; 104: 1473-1480
        • Shopp J.D.
        • Stewart L.K.
        • Emmett T.W.
        • Kline J.A
        Findings from 12-lead electrocardiography that predict circulatory shock from pulmonary embolism: systematic review and meta-analysis.
        Acad Emerg Med. 2015; 22: 1127-1137
        • Thomson D.
        • Kourounis G.
        • Trenear R.
        • Messow C.M.
        • Hrobar P.
        • Mackay A.
        • Isles C
        ECG in suspected pulmonary embolism.
        Postgrad Med J. 2019; 95: 12-17
        • Qaddoura A.
        • Digby G.C.
        • Kabali C.
        • Kukla P.
        • Zhan Z.Q.
        • Baranchuk A.M
        The value of electrocardiography in prognosticating clinical deterioration and mortality in acute pulmonary embolism: a systematic review and meta-analysis.
        Clin Cardiol. 2017; 40: 814-824