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Early ECG Warnings of RV Strain Before PEA Arrest

June 12, 2020

Written by Clay Smith

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Nearly half of inpatient PEA/asystole arrest patients had acute right ventricular strain (RVS) pattern on continuous ECG just prior to the event.

Why does this matter?
What if several minutes prior to a patient going into PEA or asystole, you had an indicator that it was about to happen? That’s what this study tells us. With AI and deep machine learning, this is a very real possibility.

Sudden RV strain…then arrest
This was a retrospective analysis of 140 adult inpatients with continuous ECG monitoring prior to PEA/asystole arrest. Patients with pulmonary hypertension, LVAD, or on ECMO were excluded. Acute signs of RV strain (RVS)* on ECG preceded arrest in almost half (47%). This was caused by PE in just 4%. Most were due to worsening respiratory illness, such as pneumonia or ARDS. For patients with RVS prior to arrest who had ROSC, echocardiogram showed new RV dysfunction in 41%. The median time RVS was initially manifest prior to arrest was 7.2 minutes. Presence of RVS prior to PEA/asystole was highly suggestive of a hypoxic/respiratory cause.

From cited article. Note, the full text article erroneously stated ECG C when they meant B. I confirmed this was in error with lead author Dr. Duc Do. He has notified the journal. The version I have written below is correct.ECG A is an 83 year old …

* Definite RVS was defined as morphological changes in lead V1, consisting of progressively delayed RV depolarization. This might include a notch in the S wave, progression to an RSR’ pattern, incomplete RBBB, or RBBB. PLUS at least 2 supporting signs of either RV ischemia or right axis deviation:

  1. ST elevation V1

  2. Rightward directed ST elevation vector in limb leads (i.e. towards lead III) or

  3. Right axis deviation in limb leads

Possible RVS was determined if V1 showed delayed RV depolarization and only one of the three supporting criteria were met.

Electrocardiographic Right Ventricular Strain Precedes Hypoxic Pulseless Electrical Activity Cardiac Arrests: Looking Beyond Pulmonary Embolism. Resuscitation. 2020 Apr 29;151:127-134. doi: 10.1016/j.resuscitation.2020.04.024. Online ahead of print.

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