Scenario: This 12-lead ECG is from a 78-year-old woman who came to the emergency department with chest pain and shortness of breath that became progressively worse. She described the pain as an elephant sitting on her chest. The symptoms were present at both rest and with exertion and associated with 1 episode of hemoptysis. She also reported generalized weakness, diaphoresis, and light-headedness. Her medical history was significant for hypertension and dyslipidemia. Her cardiac workup revealed elevated levels of troponin and brain natriuretic peptide.

This ECG shows sinus tachycardia, incomplete right bundle branch block, anteroseptal T-wave inversion (V1 to V5) and a significant shift of the electrical vector toward the right ventricle (ie, negative QRS in V6). All of these signify right ventricular strain associated with acute cor pulmonale. The deep S wave in lead I and the pathologic Q wave and inverted T wave...

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