Correspondence
A Crisis in Late Pregnancy
N Engl J Med 2010; 362:857-858March 4, 2010
- Article
To the Editor:
In the article by Desai et al. (Dec. 3 issue),1 the electrocardiogram has the characteristics of one with the right-arm and left-arm cables exchanged, resulting in the appearance of lead I as a mirror image and leads aVL and aVR exchanged. The correctly connected electrocardiograph would show an ST-segment elevation only in leads aVR and aVL; this pattern would be more suggestive of diffuse myocardial injury than localized injury and would be consistent with catecholamine-induced injury.
E. William Hancock, M.D.
Stanford University Medical Center, Palo Alto, CA
whancock@cvmed.stanford. edu No potential conflict of interest relevant to this letter was reported.
1 References1
Desai AS ,Chutkow WA ,Edelman E ,Economy KE ,Dec GW Jr . A crisis in late pregnancy. N Engl J Med 2009;361:2271-2277
Full Text | Web of Science | Medline
Author/Editor Response
We agree with Hancock that the electrocardiogram presented in Figure 1 of our article has the typical characteristics of arm-lead transposition, with implications as outlined for the appearance of the tracing. This was the tracing used by the clinicians managing the case. All electrocardiographic tracings from the initial presentation reflect the same lead placement; the abnormality was not corrected until later in the patient's clinical course, by which time the acute ST-segment changes shown in the figure had resolved. The technical error was considered in the short term by the clinical team but did not ultimately influence the differential diagnosis and management strategy as discussed. Although the overall presentation was indeed most consistent with diffuse myocardial injury, it was still necessary to definitively rule out an acute coronary process in this young pregnant woman with abrupt-onset heart failure, prompting coronary angiography after appropriate medical stabilization.
Akshay S. Desai, M.D., M.P.H.
William A. Chutkow, M.D., Ph.D.
Brigham and Women's Hospital, Boston, MAG. William Dec, Jr., M.D.
Massachusetts General Hospital, Boston, MASince publication of their article, the authors report no further potential conflict of interest.
