Written by Graham Van Schaik
In patients with acute pulmonary embolism (PE), only supraventricular tachycardia (SVT) was an independent predictor of clinical deterioration (CD); however, other ECG findings (below) were associated with abnormal RV function (abnl-RV) on echo.
Why does this matter?
As emergency physicians, PE should always be on our differential for chest pain, shortness of breath, syncope, etc. Once we’ve found a PE, it is helpful to have a sense of who might need a higher level of care to prevent CD, particularly as these patients remain boarded in our departments. Having parameters by which we can risk-stratify patients gives us a sense of who needs a little more attention.
Take my breath away…
This was a prospective, multicenter study of 1,736 newly confirmed PE patients. Of the 1,629 patients with both ECG and echo, ~25% experienced CD, defined as respiratory failure, hypotension, dysrhythmia, cardiac arrest, escalated PE intervention, or death within 5 days. Of the same 1,629 patients, ~32% had abnl-RV, which had an OR for CD of 4.25 (3.35, 5.38). On the other hand, absence of abnormal ECG findings had an OR for CD of 0.34 and abnl-RV 0.24, both statistically significant.
Only one ECG pattern had a significant OR of 2.87 for CD – SVT. T-wave inversions in V2-4, incomplete right bundle branch block, ST elevation in aVR, sinus tachycardia, and S1-Q3-T3 were all independent predictors of abnl-RV on echocardiogram.
Electrocardiographic findings associated with early clinical deterioration in acute pulmonary embolism. Acad Emerg Med. 2022 Jun 24. doi: 10.1111/acem.14554. Online ahead of print.
Shout of to Dr. Bo Stubblefield who was kind enough to let me walk into his PE-kingdom. He provided some supplemental literature for those who wish to know more:
- Findings From 12-lead Electrocardiography That Predict Circulatory Shock From Pulmonary Embolism: Systematic Review and Meta-analysis: https://pubmed.ncbi.nlm.nih.gov/26394330/
- Not All Electrocardiographic ST-Elevations Are Acute Coronary Occlusions: https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2786218
- Missed Signs of Acute Pulmonary Embolism in Electrocardiogram Finding: https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2790394
- Assessment of Cardiac Stress From Massive Pulmonary Embolism With 12-Lead ECG*: https://pubmed.ncbi.nlm.nih.gov/11502646/
- Right bundle branch block and SIQIII-type patterns for risk stratification in acute pulmonary embolism: https://pubmed.ncbi.nlm.nih.gov/27083328/