ECG findings in PULMONARY EMBOLISM
ALI FARZAD, M.D. Baylor University Medical Center - Dallas, TX March 26th, 2015 OBJECTIVE Discuss the various ECG findings seen in patients with pulmonary embolism GOAL Learn to identify ECG abnormalities in PE and SAVE LIVES!
RV OUTFLOW OBSTRUCTION h RV AFTERLOAD h 02 Demand h PA and R Heart Pres. Pressure & Vol Overload RA & RV Dilatation RV Dysfunction i LV filling i SV & CO RV ischemia/infarction COR PULMONALE ECG findings in PE
Sinus tachycardia Axis changes “RV strain pattern” - (RAD, P-Pulmonale, RBBB, TWI) Atrial & Ventricular Dysrhythmias “Ischemia” - STE/STD, TWI Normal ECG NORMAL ECGs in PEs
Low sensitivity and specificity
~20% have NORMAL ECGs
No ECG pattern is pathognomonic
Useful for prognosis and significance of PE
Chan et al. Journal of Emergency Medicine. 2001 Sinus Tachycardia + TWI Sinus Tachycardia + IRBBB Rhythm in PE
Sinus Tachycardia
1st Degree AV Block
PACs & PVCs
Atrial Fibrillation & Flutter
Chan et al. Journal of Emergency Medicine. 2001 Rightward Axis
TWI in anterior leads Axis in PE
RAD - Classic
Extreme or superior RAD
LAD - greater
frequency?
Chan et al. Journal of Emergency Medicine. 2001 S1Q3T3
1.S1Q3T3
10-50% of PEs, Transient S1Q3T3
Sign of Acute Cor Pulmonale
Acute pressure and volume overload
S1 = RBBB Q3T3 = Repol Abn Right Heart Strain S1Q3 or S1Q3T3 (McGinn & White) • Described in 1930s • Varied incidence • Transient • Not pathognomonic – PTX, Bronchospasm, etc… Right Heart Strain
Studied ECG findings of PE in 6049 patients, 354 of whom had PE. • S1Q3T3 = LR + 3.7 • TWI V1-V4 = + 3.7 • Tachycardia = LR +1.8 • IRBBB = LR + 1.7
Marchick et al. Annals of Emergency Medicine. 2010 RBBB
ST, RBBB, TWI V1-3 & Inf Anterior & Inferior TWIs New Anterior & Inferior TWIs
COR PULMONALE with
RV Pressure Overload
and Enlargement
Impaired myocardial
perfusion
Catecholamine &
Histamine release New Anterior & Inferior TWIs Ferrari et al. Chest. 1997
68% of 80 patients with acute PE had new TWI Correlated with severity of PE
Punukollu et al. Americal Journal of Cardiology. 2005
TWI in 43% of patients
Choi et al. Korean J Intern Med. 2012
TWI in precordial leads was strongest predictor of RV dysfunction (OR: 22.4) TWI’s: PE vs ACS
40 patients with Acute PE vs. 77 with ACS
BOTH had TWI
- ACS patients had more TWI in lateral leads
- PE patients had more TWI inferior + V1/V2
- TWI in lead III + V1
- PE - 88% vs ACS - 1%
Kosuge et al. American Journal of Cardiology. 2007 TWI’s: Prognosis in PE
N= 40 patients with Acute PE
- More leads with TWI = worst short term prognosis
- TWI in > 7 leads vs. TWI in < 3 leads had more complications (46% vs 0%).
Kosuge et al. Circulation Journal. 2006 TWI’s: Prognosis in PE
N ~ 440 patients with Acute PE
- TWI in 62% (35% precordial, 27% with precordial and limb)
- TWI in > 5 leads vs. < 5 leads had higher mortality (17 vs 7%) and more complications (32% vs 18%)
- TWI in > 5 leads = higher rates of lyrics and pressors
Kulka et al. Prognostic Value of TWI in PE. Heart Lung. 2015 The Pearls
New anterior and inferior TWIs suggests Acute Pulmonary HTN & PE
More TWI (# of leads & amplitude) = Increased mortality and complications 63 YO, CP, s/p Arrest! PE May Mimic ACS
STE or STD
New TWIs
Global Ischemia
– STE in aVR with diffuse STD PE with Ischemic ECG Pattern
N = 500 patients with intermediate risk PE
– Ischemic ECG pattern on admission was an independent risk factor for worse in- hospital outcomes. – Absence of ischemic ECG associated with more benign hospital course.
Kulka et al. Am J Emerg Med. 2014 P-Pulmonale
> 2.5 mV in lead II Massive PE
Zhan et al. Annals of Noninvasive Electrocardiology. 2014
Abarca et al. Journal of Electrocardiography. 2014 51 YOM with DOE, 80/64, 83%
Massive PE - TWI Massive PE
ST, RBBB, S1Q3T3 Crashing PE 130/70 65/40
ST S1Q3T3
STE avR & III
STD I, II, aVL, Crashing PE 130/70 65/40 ST S1Q3T3 Qr V1
STE avR,III, & V1
STD I, II, aVL, V4-5 Crashing PE 105/60 80/60
S1Q3
STE II, III, aVF
STD I, aVL Crashing PE 105/60 80/60
S1Q3 Qr V1
STE II, III, aVF & V1-4
STD I, aVL, V6 Let’s Summarize ECG findings in PE
Normal or Non-specific
Sinus tachycardia
Axis changes
“RV strain pattern”
-S1Q3T3, P-Pulmonale, RBBB, TWI
Atrial & Ventricular Dysrhythmias
“Ischemia” - STE/STD, TWI The Final Pearls
ECG is not sensitive for PE Useful for prognosis in significant PE’s
New TWI in AS + INF leads = Acute Pulmonary HTN = PE until proven otherwise
More TWI (# of leads & amplitude) = Increased mortality and complications THANK YOU!
@alifarzadmd