What ECG Findings Predict Crashing in Acute PE?
August 26, 2022
Written by Graham Van Schaik
Spoon Feed
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.
Source
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.
Another Spoonful
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/