BMJ Case Reports 2013; doi:10.1136/bcr-2013-009623

McConnell sign and S1Q3T3 pattern in pulmonary embolism: revisited

  1. M Chadi Alraies4
  1. 1Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio, USA
  2. 2American University of Beirut Medical Center, Beirut, Beirut, Lebanon
  3. 3Department of Pulmonary Diseases, Critical Care, & Environmental Medicine, Tulane University Health Sciences Center, New Orleans, Louisiana, USA
  4. 4Department of Hospital Medicine, Cleveland Clinic, Cleveland, Ohio, USA
  1. Correspondence to Dr M Chadi Alraies, alraies{at}


A 67-year-old man with a known history of venous thromboembolism was admitted with a 2 week history of dyspnoea. He denied chest pain, leg swelling or recent travelling. Clinical examination revealed blood pressure of 124/68 mm Hg, regular pulse of 54 bpm and respiratory rate of 27/min. Jugular veins were distended at 7 cm, and cardiopulmonary examination revealed no findings. ECG showed sinus bradycardia, S wave in lead I, Q wave in lead III with T-wave inversion (S1Q3T3) (figure 1A). Troponin T was negative and NT proBNP was elevated at 937 pg/ml. CT pulmonary angiography showed bilateral pulmonary embolism (figure 1B). Transthoracic echocardiogram revealed a moderately dilated right ventricle (RV) with moderate dysfunction. The RV apex was hyperkinetic and the free wall segment was akinetic, a finding consistent with McConnell sign (figure 1C). Anticoagulation was started, and the patient was discharged home in a stable condition. A repeat echocardiogram 2 months later showed disappearance of McConnell sign (figure 1D).1 ,2

Figure 1

(A) 12-lead ECG showing sinus bradycardia, S wave in lead I, Q wave in lead III with T-wave inversion (S1Q3T3); (B) CT pulmonary angiogram showing large clots in right and left main pulmonary arteries (arrows); (C) apical-four-chamber view on transthoracic echocardiogram showing normokinesia of the right ventricular apical segment (thin arrow) and akinesia of the midfree wall (thick arrow). LV, left ventricle; RV, right ventricle; (D) apical-four-chamber view on transthoracic echocardiogram postanticoagulation showing resolution of right ventricular wall motion abnormalities. LV, left ventricle; RV, right ventricle.

Learning points

  • The role of transthoracic echocardiography in patients with pulmonary embolism is to evaluate haemodynamic stability, pulmonary hypertension and right ventricular (RV) strain.

  • The McConnell sign, identified as RV-free wall hypokinesia with hyperkinetic apex, is sensitive and specific in pulmonary embolism, and is associated with worse outcomes.


  • Contributors All authors have been involved in drafting the article and revising it critically for important intellectual content, and read and approved the final version of the manuscript.

  • Competing interests None.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.


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