T-wave inversion is commonly associated with acute coronary syndrome (ACS). Simultaneous T wave inversions in the inferior (II, III, aVF) and right precordial leads (V1-4) is the most specific finding in favour of PE, with reported specificities of up to 99% in one study.ĮCG findings compared to Acute Coronary Syndrome Non-specific ST segment and T wave changes, including ST elevation and depression (50%).Atrial tachyarrhythmias – AF, flutter, atrial tachycardia (8%).Clockwise rotation – shift of the R/S transition point towards V6 with a persistent S wave in V6 (“pulmonary disease pattern”), implying rotation of the heart due to right ventricular dilatation.This “classic” finding is neither sensitive nor specific for PE S I Q III T III pattern – deep S wave in lead I, Q wave in III, inverted T wave in III (20%).Right atrial enlargement (P pulmonale) – peaked P wave in lead II > 2.5 mm in height (9%).Dominant R wave in V1 – a manifestation of acute right ventricular dilatation.Extreme right axis deviation may occur, with axis between zero and -90 degrees, giving the appearance of left axis deviation (“pseudo left axis”) This pattern is associated with high pulmonary artery pressures (34%) Right ventricular strain pattern – T wave inversions in the right precordial leads (V1-4) ± the inferior leads (II, III, aVF).Sinus tachycardia – the most common abnormality (seen in 44% of patients with PE).

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