ECG findings in

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 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 + 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 . 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