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.