Preview

Rational Pharmacotherapy in Cardiology

Advanced search

Prognostic Value of ECG in Patients with Pulmonary Embolism

https://doi.org/10.20996/1819-6446-2019-15-1-63-68

Full Text:

Abstract

Aim. To study the significance of electrocardiography (ECG) signs for determining the hospital prognosis in patients with pulmonary embolism (PE).

Material and methods. 472 consecutive patients (49.6% men; average age 58.06±14.28 years) with PE, hospitalized to our center from 23.04.2003 to 18.09.2014 were enrolled into the study. In all cases PE was confirmed by computed tomographic pulmonary angiography and rarely by pulmonary angiography, or by pathology. Patients management was in accordance with appropriate European guidelines. Data of patients' history, clinical symptoms, biochemical markers and instrumental methods (ECG, echocardiography) were analyzed by one-dimensional logistic regression. The end points were: death, shock and hypotension, right ventricular dysfunction and pulmonary hypertension, positive cardiac biomarkers.

pulmonary embolism, electrocardiography, prognosis, collapse, hypotension, dysfunction of the right ventricle. 443 patients (93.9%) without fatal outcome were the first group and 29 patients (6.1%) with a fatal outcome – the second group. SIQIII pattern (33 vs 55.2%; p=0.015), non-complete right bundle branch block (RBBB) (16.3 vs 37.9%; p=0.001), ST segment elevation in lead III (9.7 vs 20.7%, p=0.034), atrial fibrillation (12.9 vs 37.9%, p=0.048) were observed more frequently among patients of group 2. Multivariate analysis revealed that SIQIII pattern (odds ratio [OR] 2.26; 95% confidence interval [95%CI] 1.046-4.868; p=0.038) and RBBB (OR 2.84; 95%CI 1.272-6.327; p=0.011) were associated with worse prognosis. The SIQIII pattern was significantly associated with a fatal outcome with a sensitivity of 55% and a specificity of 33% (AUC=0.611) according to ROC-analysis. Risk of hypotension was related to the following ECG-signs: the p-pulmonale (OR 1.76; 95%CI 1.001-3.088; p=0.049), negative T-wave in lead III (OR 1.8; 95%CI 1.035-3.144; p=0.037). Inversion of the T wave in lead III was associated with the development of shock (OR 1.98; 95%CI 0.891-4.430; p=0.043).

ECG-signs were also associated with the development of right ventricular dysfunction and pulmonary hypertension: right axis deviation (OR 1.035; 95%CI 1.008-1.062; p=0.01), ST-segment elevation in the AVR lead (OR 3.769; 95%CI 1.018-13.955; p=0.047), negative T wave in leads III, V1-V3 (OR 1.015; 95%CI 1.008-1.023; p=0.001 and OR 1.014; 95%CI 1.005-1.022; p=0.001, respectively), RBBB (OR 1.013; 95%CI 1.003- 1.024; p=0.012), p-pulmonale (OR 1.015; 95%CI 1.007-1.023; p=0.001), deep S in leads V5-V6 (OR 1.015; 95%CI 1.006-1.024; p=0.001). However, there was no significant relationship between ECG signs and cardiac biomarkers (troponin I and BNP).

Conclusions. SIQIII pattern, RBBB and inversion of the T wave in lead III have prognostic value in unselected population of patients with PE. 

About the Authors

I. S. Mullova
Samara Regional Cardiology Dispensary; Samara State Medical University
Russian Federation

Cardiologist, Chapaevskaya ul. 89, Samara, 443099;

 

MD, Post-Graduate Student, Chair of Cardiology and Cardiovascular Surgery, Aerodromnaya ul. 43, Samara, 443070



T. V. Pavlova
Samara Regional Cardiology Dispensary
Russian Federation

MD, PhD, Professor, Chair of Cardiology and Cardiovascular Surgery, 

Chapaevskaya ul. 89, Samara, 443099



S. M. Khokhlunov
Samara Regional Cardiology Dispensary
Russian Federation

MD, PhD, Professor, Head of Chair of Cardiology and Cardiovascular Surgery,

Chapaevskaya ul. 89, Samara, 443099



D. V. Duplyakov
Samara Regional Cardiology Dispensary; Samara State Medical University
Russian Federation

Medical Director, Chapaevskaya ul. 89, Samara, 443099;

MD, PhD, Professor, Chair of Cardiology and Cardiovascular Surgery, Aerodromnaya ul. 43, Samara, 443070



References

1. Kukla P., McIntyre W.F., Fijorek K., et al. Electrocardiographic abnormalities in patients with acute pulmonary embolism complicated by cardiogenic shock. Am J Emerg Med. 2014;32(6):507-10. doi:10.1016/j.ajem.2014.01.043.

2. Bogorodskij A.Yu., Ruban V.V., Kuligin A.V. Features of hemodynamic and gas exchange in patients with thromboembolism of small pulmonary artery branches. Cardiology: News, Opinions, Training. 2018;6(2):73-8. (In Russ.) doi:10.24411/2309-1908-2018-12009.

3. Wiener R.S., Schwartz L.M., Woloshin S. Time trends in pulmonary embolism in the United States: evidence of over diagnosis. Arch Intern Med. 2011;171:831-7. doi:10.1001/archinternmed. 2011.178.

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

5. Wellens H.J.J. ECG recognition of acute pulmonary embolism. In: Wellens H.J.J., Conover M.B., eds. The ECG in emergency decision making. 2-nd Edition. St. Louis: Saunders/Elsevier; 2006; 185-95.

6. Rodger M., Makropoulos D., Turek M., et al. Diagnostic value of the electrocardiogram in suspected pulmonary embolism. Am J Cardiol. 2000;86:807-9.

7. Sreeram N., Cheriex E.C., Smeets J.L., et al. Value of the 12-lead electrocardiogram at hospital admission in the diagnosis of pulmonary embolism. Am J Cardiol. 1994;73:298-303.

8. Kosuge M., Kimura K., Ishikawa T., et al. Electrocardiographic differentiation between acute pulmonary embolism and acute coronary syndromes on the basis of negative T waves. Am J Cardiol. 2007;99:817-21. doi:10.1016/j.amjcard.2006.10.043.

9. Daniel K., Courtney D., Kline J.A. Assessment of cardiac stress from massive pulmonary embolism with 12-lead ECG. Chest. 2001;120:474-81.

10. Tayama E., Ouchida M., Teshima H., et al. Treatment of acute massive/submassive pulmonary embolism. Circ J. 2002;66:479-83.

11. Geibel A., Zehender M., Kasper W., et al. Prognostic value of the ECG on admission in patients with acute major pulmonary embolism. Eur Respir J. 2005;25:843-8. doi:10.1183/09031936.05.00119704.

12. Torbicki A., Perrier A., Konstantinides S., et al. Guidelines on the diagnosis and management of acute pulmonary embolism: The Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). Eur Heart J. 2008;29:2276-315. doi:10.1093/eurheartj/ehn310.

13. Konstantinides S.V., Torbicki A., Agnelli G., et al. 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J. 2014;35(43):3033-69. doi:10.1093/eurheartj/ehu283.

14. Kostrubiec M., Hrynkiewicz A., Pedowska-Wloszek J., et al. Is it possible to use standard electrocardiography for risk assessment of patients with pulmonary embolism? Kardiologia Polska. 2009;67:744-50.

15. Kline J.A., Hernandez-Nino J., Rose G.A., et al. Surrogate markers for adverse outcomes in normotensive patients with pulmonary embolism. Crit Care Med. 2006;34:2773-80.

16. Sinha N., Yalamanchili K., Sukhija R., et al. Role of the 12- lead electrocardiogram in diagnosing pulmonary embolism. Cardiol Rev. 2005;13:46-9.

17. Stein P.D., Dalen J.E., McIntyre K.M., et al. The electrocardiogram in acute pulmonary embolism. Prog Cardiovasc Dis. 1975;17:247-57. 18. Kim S.E., Park D.G., Choi H.H., et al. The best predictor for right ventricular dysfunction in acute pulmonary embolism: comparison between electrocardiography and biomarkers. Kor Circ J. 2009;39:378-81.


For citation:


Mullova I.S., Pavlova T.V., Khokhlunov S.M., Duplyakov D.V. Prognostic Value of ECG in Patients with Pulmonary Embolism. Rational Pharmacotherapy in Cardiology. 2019;15(1):63-68. (In Russ.) https://doi.org/10.20996/1819-6446-2019-15-1-63-68

Views: 169


Creative Commons License
This work is licensed under a Creative Commons Attribution 4.0 License.


ISSN 1819-6446 (Print)
ISSN 2225-3653 (Online)