Association of different electrocardiographic patterns with shock index, right ventricle systolic pressure and diameter, and embolic burden score in pulmonary embolism

Bojana Krća; Boris Džudović; Snježana Vukotić; Nenad Ratković; Bojana Subotić; Danijela Vraneš; Siniša Rusović; Slobodan Obradović

doi:10.2298/VSP150512011K

Bojana Krća Military Medical Academy Medical Faculty, University of Defence, Belgrade
Boris Džudović Clinic of Emergency Medicine, Military Medical Academy, Belgrade, Serbia
Snježana Vukotić Clinic of Emergency Medicine, Military Medical Academy, Belgrade, Serbia
Nenad Ratković Faculty of Medicine of the Military Medical Academy, University of Defence, Belgrade, Serbia; Clinic of Emergency Medicine, Military Medical Academy, Belgrade, Serbia
Bojana Subotić Clinic of Emergency Medicine, Military Medical Academy, Belgrade, Serbia
Danijela Vraneš Clinic of Emergency Medicine, Military Medical Academy, Belgrade, Serbia
Siniša Rusović Institute of Radiology, Military Medical Academy, Belgrade, Serbia
Slobodan Obradović Faculty of Medicine of the Military Medical Academy, University of Defence, Belgrade, Serbia; Clinic of Emergency Medicine, Military Medical Academy, Belgrade, Serbia

DOI: https://doi.org/10.2298/VSP150512011K

Keywords: pulmonary embolism, electrocardiography, diagnosis, differential, tomography, angiography, ventricular function, right, sensitivity and specificity,

Abstract

Background/Aim. Some electrocardiographic (ECG) patterns are characteristic for pulmonary embolism but exact meaning of the different ECG signs are not well known. The aim of this study was to determine the association between four common ECG signs in pulmonary embolism [complete or incomplete right bundle branch block (RBBB), S-waves in the aVL lead, S₁Q₃T₃ sign and negative T-waves in the precordial leads] with shock index (SI), right ventricle diastolic diameter (RVDD) and peak systolic pressure (RVSP) and embolic burden score (EBS). Methods. The presence of complete or incomplete RBBB, S waves in aVL lead, S₁Q₃T₃sign and negative T-waves in the precordial leads were determined at admission ECG in 130 consecutive patients admitted to the intensive care unit of a single tertiary medical center in a 5-year period. Echocardiography examination with measurement of RVDD and RVSP, multidetector computed tomography pulmonary angiography (MDCT-PA) with the calculation of EBS and SI was determined during the admission process. Multivariable regression models were calculated with ECG parameters as independent variables and the mentioned ultrasound, MDCT-PA parameters and SI as dependent variables. Results. The presence of S-waves in the aVL was the only independent predictor of RVDD (F = 39.430, p < 0.001; adjusted R² = 0.231) and systolic peak right ventricle pressure (F = 29.903, p < 0.001; adjusted R² = 0.185). Negative T-waves in precordial leads were the only independent predictor for EBS (F = 24.177, p < 0.001; R² = 0.160). Complete or incomplete RBBB was the independent predictor of SI (F = 20.980, p < 0.001; adjusted R² = 0.134). Conclusion. In patients with pulmonary embolism different ECG patterns at admission correlate with different clinical, ultrasound and MDCT-PA parameters. RBBB is associated with shock, S-wave in the aVL is associated with right ventricle pressure and negative T-waves with the thrombus burden in the pulmonary tree.

References

Goldhaber SZ, Visani L, De Rosa M. Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet 1999; 353(9162): 1386−9.

Konstantinides SV, Torbicki A, Agnelli G, Danchin N, Fitzmaurice D, Galiè N, et al. 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J 2014; 35(43): 3030−80.

Perrier A, Roy P, Sanchez O, Le Gal G, Meyer G, Gourdier A, et al. Multidetector-row computed tomography in suspected pul-monary embolism. N Engl J Med 2005; 352(17): 1760−8.

Panos RJ, Barish RA, Whye DW Jr, Groleau G. The electrocardi-ographic manifestations of pulmonary embolism. J Emerg Med 1988; 6(4): 301−7.

Toosi MS, Merlino JD, Leeper KV. Prognostic value of the shock index along with transthoracic echocardiography in risk strati-fication of patients with acute pulmonary embolism. Am J Cardiol 2008; 101(5): 700−5.

Qanadli SD, El Hajjam M, Vieillard-Baron A, Joseph T, Mesurolle B, Oliva VL, et al. New CT index to quantify arterial obstruction in pulmonary embolism: comparison with angiographic index and echocardiography. AJR Am J Roentgenol 2001; 176(6): 1415−20.

Petrov DB. Appearance of right bundle branch block in electro-cardiograms of patients with pulmonary embolism as a marker for obstruction of the main pulmonary trunk. J Elec-trocardiol 2001; 34(3): 185−8.

Sreeram N, Cheriex EC, Smeets JL, Gorgels AP, Wellens HJ. Value of the 12-lead electrocardiogram at hospital admission in the diagnosis of pulmonary embolism. Am J Cardiol 1994; 73(4): 298−303.

Kukla P, McIntyre WF, Fijorek K, Mirek-Bryniarska E, Bryniarski L, Krupa E, et al. Electrocardiographic abnormalities in pa-tients with acute pulmonary embolism complicated by cardi-ogenic shock. Am J Emerg Med 2014; 32(6): 507−10.

Janata K, Höchtl T, Wenzel C, Jarai R, Fellner B, Geppert A, et al. The role of ST-segment elevation in lead aVR in the risk as-sessment of patients with acute pulmonary embolism. Clin Res Cardiol 2012; 101(5): 329−37.

Digby GC, Kukla P, Zhan Z, Pastore CA, Piotrowicz R, Schapachnik E, et al. The value of electrocardiographic abnormalities in the prognosis of pulmonary embolism: A consensus paper. Ann Noninvasive Electrocardiol 2015; 20(3): 207−23.

Ryu HM, Lee JH, Kwon YS, Lee SH, Bae MH, Lee JH, et al. Elec-trocardiography patterns and the role of the electrocardiogra-phy score for risk stratification in acute pulmonary embolism. Korean Circ J 2010; 40(10): 499−506.

Daniel KR, Courtney DM, Kline JA. Assessment of cardiac stress from massive pulmonary embolism with 12-lead ECG. Chest 2001; 120(2): 474−81.

Stein PD, Matta F, Sabra MJ, Treadaway B, Vijapura C, Warren R, et al. Relation of electrocardiographic changes in pulmonary embolism to right ventricular enlargement. Am J Cardiol 2013; 112(12): 1958−61.

Sukhija R, Aronow WS, Ahn C, Kakar P. Electrocardiographic abnormalities in patients with right ventricular dilation due to acute pulmonary embolism. Cardiology 2006; 105(1): 57−60.

Hariharan P, Dudzinski DM, Okechukwu I, Takayesu JK, Chang Y, Kabrhel C. Association between electrocardiographic findings, right heart strain, and short-term adverse clinical events in pa-tients with acute pulmonary embolism. Clin Cardiol 2015; 38(4): 236−42.

Love Jr WS, Brugler GW, Winslow N. Electrocardiographic stu-dies in clinical and experimental pulmonary embolization. Arch Intern Med 1938; 11: 2109−23.

Geibel A, Zehender M, Kasper W, Olschewski M, Klima C, Konstan-tinides SV. Prognostic value of the ECG on admission in pa-tients with acute major pulmonary embolism. Eur Respir J 2005; 25(5): 843−8.

Punukollu G, Gowda RM, Vasavada BC, Khan IA. Role of elec-trocardiography in identifying right ventricular dysfunction in acute pulmonary embolism. Am J Cardiol 2005; 96(3): 450−2.

Ferrari E, Imbert A, Chevalier T, Mihoubi A, Morand P, Baudouy M. The ECG in pulmonary embolism: Predictive value of neg-ative T waves in precordial leads: 80 case reports. Chest 1997; 111(3): 537−43.

Choi B, Park D. Normalization of negative T-wave on electro-cardiography and right ventricular dysfunction in patients with an acute pulmonary embolism. Korean J Intern Med 2012; 27(1): 53−9.

McIntyre KM, Sasahara AA, Littmann D. Relation of the electro-cardiogram to hemodynamic alterations in pulmonary embol-ism. Am J Cardiol 1972; 30(3): 205−10.

Kukla P, McIntyre WF, Fijorek K, Długopolski R, Mirek-Bryniarska E, Bryniarski KL, et al. T-wave inversion in patients with acute pulmonary embolism: prognostic value. Heart Lung 2015; 44(1): 68−71.

Kukla P, Długopolski R, Krupa E, Furtak R, Wrabec K, Szełemej R,et al. The value of ECG parameters in estimating myocardial injury and establishing prognosis in patients with acute pul-monary embolism. Kardiol Pol 2011; 69(9): 933−8.