Clinical research study
Prognostic Value of ECG Among Patients with Acute Pulmonary Embolism and Normal Blood Pressure

https://doi.org/10.1016/j.amjmed.2008.08.031Get rights and content

Abstract

Objective

To investigate the prognostic value of electrocardiography (ECG) alone or in combination with echocardiography in patients with acute pulmonary embolism and normal blood pressure.

Methods

Consecutive adult patients presenting to the emergency department at Azienda Ospedaliero-Universitaria Careggi with the first episode of pulmonary embolism were included. Patients with systolic blood pressure less than 100 mm Hg were excluded. ECG and echocardiography were performed within 1 hour from diagnosis and evaluated in a blinded fashion. Right ventricular strain was diagnosed in the presence of one or more of the following ECG findings: complete or incomplete right ventricular branch block, S1Q3T3, and negative T wave in V1-V4. The main outcome measurement was clinical deterioration or death during in-hospital stay. The association of variables with the main outcome was evaluated by multivariate Cox survival analysis.

Results

A total of 386 patients with proved pulmonary embolism were included in the study; 201 patients (52%) had right ventricular dysfunction according to echocardiography, and 130 patients (34%) showed right ventricular strain. Twenty-three patients (6%) had clinical deterioration or died. At multivariate survival analysis, right ventricular strain was associated with adverse outcome (hazard ratio 2.58; 95% confidence interval, 1.05-6.36) independently of echocardiographic findings. Patients with both right ventricular strain and right ventricular dysfunction (26%) showed an 8-fold elevated risk of adverse outcome (hazard ratio 8.47; 95% confidence interval, 2.43-29.47).

Conclusion

Right ventricular strain pattern on ECG is associated with adverse short-term outcome and adds incremental prognostic value to echocardiographic evidence of right ventricular dysfunction in patients with acute pulmonary embolism and normal blood pressure.

Section snippets

Setting and Selection of Participants

Consecutive adult patients who presented from January 1998 to June 2006 to the emergency department of a third-level teaching hospital (Careggi, Florence, Italy) with the clinical suspicion of pulmonary embolism were considered for the study. Exclusion criteria were systolic arterial pressure persistently less than 100 mm Hg, a prior documented episode of pulmonary embolism, and a history of severe chronic obstructive pulmonary disease or echocardiographic signs of long-term right ventricular

Patients and Management

A total of 557 consecutive patients with an objectively confirmed acute pulmonary embolism were considered for the study from January 1998 to June 2006. Of these patients, 36 were excluded because of shock on admission (7%), whereas 123 additional patients (22%) were excluded because they had a documented previous episode of pulmonary embolism (50 patients), were affected by severe chronic obstructive pulmonary disease, had echocardiographic signs of long-standing right ventricular overload (63

Discussion

The present study demonstrates the association of right ventricular strain pattern showed by the presentation ECG with adverse short-term outcome (clinical deterioration or death) in patients with acute pulmonary embolism and normal blood pressure. In addition, right ventricular strain was found to add incremental prognostic value to echocardiographic evidence of right ventricular dysfunction.

A large body of evidence has shown that although ECG may reveal several abnormalities in pulmonary

Conclusions

The present study of normotensive patients with pulmonary embolism revealed that right ventricular strain pattern at ECG is associated with short-term clinical deterioration and death. When combined with echocardiography, right ventricular strain was better able to recognize normotensive patients at high risk of clinical deterioration. These patients might benefit by strict surveillance during hospital stay and careful evaluation for pulmonary reperfusion therapy.

References (23)

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    Short-term clinical outcome of patients with acute pulmonary embolism, normal blood pressure, and echocardiographic right ventricular dysfunction

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      Right ventricular dysfunction is associated with an increased clot burden6 and is a significant prognostic factor in pulmonary embolism.7–9 The presence of several of these ECG signs has been related to an increase in short-term mortality and clinical deterioration among patients with pulmonary embolism in prospective2,3,10–13 and retrospective studies.4,14 As such, ECG might serve as an easily available prognostic tool to help guide management of patients with acute pulmonary embolism.

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    Funding: None.

    Conflict of Interest: None of the authors have any conflicts of interest associated with the work presented in this manuscript.

    Authorship: All authors had access to the data and played a role in writing this manuscript.

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