ECG Score Predicts Those With the Greatest Percentage of Perfusion Defects Due to Acute Pulmonary Thromboembolic Disease

APACHE II-ECG scoring system: A novel and strong predictor of in-hospital mortality for patients treated in intensive care unit

Some novel electrocardiographic (ECG) parameters, such as T-wave peak to T-wave end duration (Tp-Te) and Tp-Te/Q-T interval (QT) ratios, have recently been found to be associated with cardiac ischemia and effective in predicting ventricular arrhythmias and mortality. This study examined the association between ECG repolarization parameters and mortality in intensive care unit (ICU) patients. A total of 232 ICU patients were retrospectively categorized as survivors or nonsurvivors retrospectively. Laboratory, demographic, and ECG parameters were compared between the groups. A novel ECG score was measured using the QT interval, Tp-Te, and Tp-Te/QT ratio upon admission to the ICU. We compared the ECG score, Acute Physiologic and Chronic Health Evaluation II (APACHE II)-score, and APACHE II-ECG scores (the combination of APACHE II and ECG score) regarding mortality using a biostatistical program. The mean age of the 232 patients was 69.96 ± 18.01 years, and 49.1% were male. The nonsurvivor group was significantly older and had higher ECG, APACHE II, and APACHE II-ECG scores. Multivariate Cox regression analysis revealed that higher levels of all 3 scores were independent risk factors for mortality ([hazard ratio, HR (95% CI): 1.847 (1.305-2.615), P = .001], [HR (95%CI): 1.146 (1.071-1.225), P < .001], and [HR (95% CI): 1.181 (1.117-1.249), P < .001], respectively). Receiver operating curve analysis of these scoring systems for predicting mortality in the ICU revealed a stronger predictive value for the APACHE II-ECG score (AUC [95% CI]: 0.872 [0.824-0.919], P < .001, sensitivity: 88.7%, specificity: 73.3%). Kaplan-Meier survival analysis revealed the superiority of the APACHE II-ECG score in predicting the survival of ICU patients (log rank chi-square: 80.366, P < .001). Our study suggests combining ECG repolarization parameters with APACHE II score offers a new, more robust system for stronger mortality prediction in ICU patients.

Effects of balloon pulmonary angioplasty procedure on electrocardiographic parameters in patients with chronic thromboembolic pulmonary hypertension

AIM

The aim of the present study was to evaluate the value of electrocardiography (ECG) in predicting postoperative hemodynamic improvement in patients with chronic thromboembolic pulmonary hypertension (CTEPH) undergoing balloon pulmonary angioplasty (BPA).

MATERIAL AND METHODS

A total of 32 patients were included in the study. During ECG analysis, parameters that have been suggested to be related to right ventricular hypertrophy and/or dilatation were evaluated. The significance of the change in each parameter obtained at the pre-BPA visit and at the scheduled control visit 6 months after BPA was tested. In addition to ECG analysis, data related to right heart catheterization (RHC) and echocardiography, B-type natriuretic peptide (BNP) levels and World Health Organization (WHO) functional classifications of all patients were also recorded. The relationship between the amount of possible change in ECG parameters and the amount of possible change in hemodynamic parameters was investigated.

RESULTS

The Daniel score, which has been suggested to have prognostic value in acute pulmonary embolism, decreased from 8.22 ± 5.68 to 6.56 ± 5.55 after the BPA procedure (p: 0.035). Among all parameters studied, only T wave height (V₂ t) in V₂ derivation changed significantly from -0.77 ± 2.39 to 1.27 ± 2.58 mm (p: 0.036). The amount of change in V₂ T was found to significantly correlate with the amount of change in systolic right ventricular pressure, mean pulmonary artery pressure, pulmonary vascular resistance, and systemic vascular resistance.

CONCLUSION

Postprocedural T wave changes in lead V2 might serve as a marker of hemodynamic improvement in patients with CTEPH who undergo BPA.

Prognostic value of right ventricular strain pattern on ECG in COVID-19 patients

OBJECTIVE

COVID-19 spread worldwide, causing severe morbidity and mortality and this process still continues. The aim of this study to investigate the prognostic value of right ventricular (RV) strain in patients with COVID-19.

METHODS

Consecutive adult patients admitted to the emergency room for COVID-19 between 1 and 30 April were included in this study. ECG was performed on hospital admission and was evaluated as blind. RV strain was defined as in the presence of one or more of the following ECG findings: complete or incomplete right ventricular branch block (RBBB), negative T wave in V1-V4 and presence of S1Q3T3. The main outcome measure was death during hospitalization. The relationship of variables to the main outcome was evaluated by multivariable Cox regression analysis.

RESULTS

A total of 324 patients with COVID-19 were included in the study; majority of patients were male (187, 58%) and mean age was 64.2 ± 14.1. Ninety-five patients (29%) had right ventricular strain according to ECG and 66 patients (20%) had died. After a multivariable survival analysis, presence of RV strain on ECG (OR: 4.385, 95%CI: 2.226-8.638, p < 0.001), high-sensitivity troponin I (hs-TnI), d-dimer and age were independent predictors of mortality.

CONCLUSION

Presence of right ventricular strain pattern on ECG is associated with in hospital mortality in patients with COVID-19.

Prognostic Value of Electrocardiography in Elderly Patients with Acute Pulmonary Embolism

BACKGROUND

Electrocardiographic (ECG) signs of right ventricular strain could be used as a simple tool to risk-stratify patients with acute pulmonary embolism.

METHODS

We studied consecutive patients aged ≥65 years with acute pulmonary embolism in a prospective multicenter cohort study. Two readers independently analyzed 12 predefined ECG signs of right ventricular strain in all patients. The outcome was the occurrence of an adverse clinical event, defined as death from any cause within 90 days or a complicated in-hospital course. We determined the interrater reliability for each ECG sign and examined the association between right ventricular strain signs and adverse events using logistic regression, adjusting for the Pulmonary Embolism Severity Index and cardiac troponin.

RESULTS

Overall, 320/390 patients (82%) showed at least one ECG sign of right ventricular strain. The interrater reliability for individual ECG signs was highly variable (ᴋ 0.40-0.95). Patients with ≥1 of the 3 classic signs of right ventricular strain (S1Q3T3, right bundle branch block, or T wave inversions in V1-V4) had a higher incidence of adverse events than those without (13% vs 6%; P = .026). After adjustment, the presence of ≥1 of the 3 classic signs of right ventricular strain (odds ratio 2.11; 95% confidence interval, 1.00-4.46) and the number of right ventricular strain signs present were significantly associated with adverse events (odds ratio 1.35 per sign; 95% confidence interval, 1.08-1.69).

CONCLUSIONS

ECG signs of right ventricular strain are common in elderly patients with acute pulmonary embolism. Although such signs may have prognostic value, their variable reliability and the rather modest prognostic effect size may limit their usefulness in the risk stratification of pulmonary embolism.

Electrocardiographic findings in pulmonary embolism

Pulmonary embolism (PE) poses a challenge to physicians, as it can be difficult to diagnose but results in significant mortality and morbidity in patients. Diagnosing PE requires an integrated approach using clinical findings, electrocardiography (ECG), blood investigations and imaging modalities. Abnormalities in ECG are common among patients with massive acute PE and can serve as a prognostic indicator. In this article, we describe the ECG presentations of two patients diagnosed with PE, and review the literature on the various types of ECG presentations and their role in predicting the prognosis of PE.

New Electrocardiographic Changes in Patients Diagnosed with Pulmonary Embolism

BACKGROUND

The electronic medical record is a relatively new technology that allows quick review of patients' previous medical records, including previous electrocardiograms (ECGs). Previous studies have evaluated ECG patterns predictive of pulmonary embolism (PE) at the time of PE diagnosis, though none have examined ECG changes in these patients when compared with their previous ECGs.

OBJECTIVE

Our aim was to identify the most common ECG changes in patients with known PE when their ECGs were compared with their previous ECGs.

METHODS

A retrospective chart review of patients diagnosed with PE in the emergency department was performed. Each patient's presenting ECG was compared with their most recent ECG obtained before diagnosis of PE.

RESULTS

A total of 352 cases were reviewed. New T wave inversions, commonly in the inferior leads, were the most common change found, occurring in 34.4% of cases. New T wave flattening, also most commonly in the inferior leads, was the second most common change, occurring in 29.5%. A new sinus tachycardia occurred in 27.3% of cases. In 24.1% of patients, no new ECG changes were noted, with this finding more likely to occur in patients younger than 60 years.

CONCLUSIONS

The most common ECG changes when compared with previous ECG in the setting of PE are T wave inversion and flattening, most commonly in the inferior leads, and occurring in approximately one-third of cases. Approximately one-quarter of patients will have a new sinus tachycardia, and approximately one-quarter will have no change in their ECG.

Spontaneous, resolving S1Q3T3 in pulmonary embolism: A case report and literature review on prognostic value of electrocardiography score for pulmonary embolism

BACKGROUND

Electrocardiography findings in patients with pulmonary embolism have been investigated since 1935. As medicine has evolved, more effective modalities have surpassed the electrocardiogram in diagnostic utility. Despite the advent of these other modalities, the diagnosis of pulmonary embolism remains elusive and the prognosis is variable amongst each clinical presentation of its pathology.

CASE REPORT AND LITERATURE REVIEW

After presenting a case of a resolving S1Q3T3 in subsequent electrocardiogram findings of a patient with pulmonary embolism, this literature review will provide information on a 21-point electrocardiogram scoring system that helps the emergency physician stratify the risk of a patient with an acute presentation of pulmonary embolism. Why should emergency care staff be aware of this? Given the time-sensitive nature of diagnosis and appropriate treatment, Electrocardiogram continues to be a tool in the assessment of patients with a clinical suspicion of pulmonary embolism. Based on the information provided, 21-point electrocardiogram score has been shown to have strong usefulness in assessing prognosis of patients presenting with acute pulmonary embolism.

Findings From 12-lead Electrocardiography That Predict Circulatory Shock From Pulmonary Embolism: Systematic Review and Meta-analysis

OBJECTIVES

Treatment guidelines for acute pulmonary embolism (PE) recommend risk stratifying patients to assess PE severity, as those at higher risk should be considered for therapy in addition to standard anticoagulation to prevent right ventricular (RV) failure, which can cause hemodynamic collapse. The hypothesis was that 12-lead electrocardiography (ECG) can aid in this determination. The objective of this study was to measure the prognostic value of specific ECG findings (the Daniel score, which includes heart rate > 100 beats/min, presence of the S1Q3T3 pattern, incomplete and complete right bundle branch block [RBBB], and T-wave inversion in leads V1-V4, plus ST elevation in lead aVR and atrial fibrillation suggestive of RV strain from acute pulmonary hypertension), in patients with acute PE.

METHODS

Studies were identified by a structured search of MEDLINE, PubMed, EMBASE, the Cochrane library, Google Scholar, Scopus, and bibliographies in October 2014. Case reports, non-English papers, and those that lacked either patient outcomes or ECG findings were excluded. Papers with evidence of a predefined reference standard for PE and the results of 12-lead ECG, stratified by outcome (hemodynamic collapse, defined as circulatory shock requiring vasopressors or mechanical ventilation, or in hospital or death within 30 days) were included. Papers were assessed for selection and publication bias. The authors also assessed heterogeneity (I(2) ) and calculated the odds ratios (OR) for each ECG sign from the random effects model if I(2) > 24% and fixed effects if I(2) < 25%. Funnel plots were used to examine for publication bias.

RESULTS

Forty-five full-length studies of 8,209 patients were analyzed. The most frequent ECG signs found in patients with acute PE were tachycardia (38%), T-wave inversion in lead V1 (38%), and ST elevation in lead aVR (36%). Ten studies with 3,007 patients were included for full analysis. Six ECG findings (heart rate > 100 beats/min, S1Q3T3, complete RBBB, inverted T waves in V1-V4, ST elevation in aVR, and atrial fibrillation) had likelihood and ORs with lower-limit 95% confidence intervals above unity, suggesting them to be significant predictors of hemodynamic collapse and 30-day mortality. OR data showed no evidence of publication bias, but the proportions of patients with hemodynamic collapse or death and S1Q3T3 and RBBB tended to be higher in smaller studies. Patients who were outcome-negative had a significantly lower mean ± SD Daniel score (2.6 ± 1.5) than patients with hemodynamic collapse (5.9 ± 3.9; p = 0.039, ANOVA with Dunnett's post hoc), but not patients with all-cause 30-day mortality (4.9 ± 3.3; p = 0.12).

CONCLUSIONS

This systematic review and meta-analysis revealed 10 studies, including 3,007 patients with acute PE, that demonstrate that six findings of RV strain on 12-lead ECG (heart rate > 100 beats/min, S1Q3T3, complete RBBB, inverted T waves in V1-V4, ST elevation in aVR, and atrial fibrillation) are associated with increased risk of circulatory shock and death.

Electrocardiographic abnormalities in patients with acute pulmonary embolism complicated by cardiogenic shock

BACKGROUND

Cardiogenic shock (CS) is a predictor of poor prognosis in patients with acute pulmonary embolism (APE).

OBJECTIVES

The aim of this study was to compare electrocardiography (ECG) parameters in patients with APE presenting with or without CS.

METHODS

A 12-lead ECG was recorded on admission at a paper speed of 25 mm/s and 10 mm/mV amplification. All ECGs were examined by a single cardiologist who was blinded to all other clinical data. All ECG measurements were made manually.

RESULTS

Electrocardiographic data from 500 patients with APE were analyzed, including 92 patients with CS. The following ECG parameters were associated with CS: S1Q3T3 sign, (odds ratio [OR]: 2.85, P<.001), qR or QR morphology of QRS in lead V1, (OR: 3.63, P<.001), right bundle branch block (RBBB) (OR: 2.46, P=.004), QRS fragmentation in lead V1 (OR: 2.94, P=.002), low QRS voltage (OR: 3.21, P<.001), negative T waves in leads V2 to V4 (OR: 1.81, P=.011), ST-segment depression in leads V4 to V6 (OR: 3.28, P<.001), ST-segment elevation in lead III (OR: 4.2, P<.001), ST-segment elevation in lead V1 (OR: 6.78, P<.01), and ST-segment elevation in lead aVR (OR: 4.35, P<.01). The multivariate analysis showed that low QRS voltage, RBBB, and ST-segment elevation in lead V1 remained statistically significant predictors of CS.

CONCLUSIONS

In patients with APE, low QRS voltage, RBBB, and ST-segment elevation in lead V1 were associated with CS.

Management of massive and submassive pulmonary embolism

Massive pulmonary embolism has a high mortality rate despite advances in diagnosis and therapy. This article attempts to review the evidence-based risk stratification, diagnosis, initial stabilization, and management of massive and submassive pulmonary embolism.

Management of massive and nonmassive pulmonary embolism

Massive pulmonary embolism (PE) is characterized by systemic hypotension (defined as a systolic arterial pressure < 90 mm Hg or a drop in systolic arterial pressure of at least 40 mm Hg for at least 15 min which is not caused by new onset arrhythmias) or shock (manifested by evidence of tissue hypoperfusion and hypoxia, including an altered level of consciousness, oliguria, or cool, clammy extremities). Massive pulmonary embolism has a high mortality rate despite advances in diagnosis and therapy. A subgroup of patients with nonmassive PE who are hemodynamically stable but with right ventricular (RV) dysfunction or hypokinesis confirmed by echocardiography is classified as submassive PE. Their prognosis is different from that of others with non-massive PE and normal RV function. This article attempts to review the evidence-based risk stratification, diagnosis, initial stabilization, and management of massive and nonmassive pulmonary embolism.

The role of ST-segment elevation in lead aVR in the risk assessment of patients with acute pulmonary embolism

BACKGROUD AND AIM: Patients with acute pulmonary embolism (APE) present with highly variable symptoms and ECG abnormalities. As ST-elevation in lead aVR has recently been described to predict right ventricular dysfunction (RVD), we aimed to correlate this sign to the severity of APE.

METHODS

Three-hundred ninety-six consecutive patients (in centers a and b) with proven APE were retrospectively analysed with respect to 12-lead-ECG, symptoms, thrombus location, echocardiograpy, troponin T, initial therapy and outcome. Data were then compared between patients with and without aVR-ST-elevation.

RESULTS

On admission aVR-ST-elevation was present in 34.3% (n = 136). Presence of aVR-ST-elevation was assossiated with more severe clinical presentation (dyspnoea at rest 44.9 vs. 29.2%; p = 0.002, hypotension 17.0 vs. 6.5%; p = 0.001, syncope 16.2 vs. 6.5%; p = 0.002), higher median troponin T levels (0.035 [0.01-0.2] versus 0.01 [0.01-0.02]; p < 0.001), more frequent RVD (74.5 vs. 46.6%; p < 0.001) and central located thrombi (50.8 vs. 29.2; p < 0.001). Thrombolysis was used more frequently (29.1 vs. 7.5%; p < 0.001) and in-hospital-mortality was increased (10.3 vs. 5.4%; p = 0.07) when compared to patients without that sign. Mortality in intermediate-risk APE patients with aVR-ST-elevation was 8.9% compared to 0% in those without (p = 0.04). In contrast, the presence of other classical ECG pattern of APE did not further increase mortality in intermediate-risk patients.

CONCLUSIONS

ST-elevation in lead aVR is associated with a more severe course of APE, especially in patients with intermediate-risk. Therefore, aVR-ST-elevation might be useful in risk stratification of APE.

Electrocardiogram score predicts severity of pulmonary embolism in hemodynamically stable patients

BACKGROUND

Risk stratification of patients with pulmonary embolism (PE) is essential to guide therapy. The presence of right ventricle dysfunction (RVD) and the anatomic extent of PE have been suggested to predict clinical course. The aim of this study was to assess the ability of an electrocardiogram (ECG) scoring system to predict RVD or the clot load score in normotensive patients with PE.

METHODS

Consecutive patients presenting to the emergency room with PE and hemodynamic stability were prospectively included. ECG, echocardiography and computed tomography pulmonary angiography (CTPA) were performed on all patients.

RESULTS

A total of 103 patients were studied. ECG score correlated significantly with the clot load score (r = 0.41, 95% confidence interval [CI]: 0.22-0.57, P < 0.001), systolic pulmonary artery pressure (r= 0.31, 95% CI: 0.09-0.49, P = 0.006), pulmonary artery diameter (r = 0.28, 95% CI: 0.07-0.47, P = 0.011) and right ventricle to left ventricle ratio, both measured with echocardiography (r = 0.42, 95% CI: 0.22-0.57, P < 0.001) and with CTPA (r= 0.36, 95% CI: 0.13-0.56, P = 0.004). Area under the receiver operating characteristic curve for detecting RVD was 0.82 (95% CI: 0.72-0.89). Interobserver agreement regarding ECG score was substantial (κ = 0.80).

CONCLUSIONS

ECG score correlates with the severity of PE in hemodynamically stable patients. It is potentially useful for risk-stratification strategies in this setting.

QT dispersion in patients with pulmonary embolism

BACKGROUND

Various ECG patterns have been associated with acute pulmonary embolism. However, there is no data regarding the association between QT interval measurements and pulmonary embolism. We aimed to investigate the association between QT dispersion and the severity of pulmonary embolism (PE).

METHODS

One hundred twenty-nine pulmonary embolism patients (mean age 58 ± 16.5 years) with ECGs obtained within the first 24 hours of hospital admission were included in the study. Patients were classified into low, intermediate and high-risk groups. We retrospectively measured ECG scores; maximum and minimum corrected QT intervals (QTc(max) and QTc(min)) and corrected QT interval dispersion (QTcd) in each risk group of patients.

RESULTS

There was an increasing ECG score through from low to high-risk PE [3 (Interquartile Range, IQR: 2), 5 (IQR: 6) and 10 (IQR: 7) p < 0.0001]. QT interval analysis showed that QTcd was higher in high-risk group than in low and intermediate-risk groups (59.5 ± 23.4, 69.2 ± 21, 95.9 ± 33.2, p <0.001 and p = 0.01, respectively). Patients who died after diagnosis had significantly higher QTcd values at baseline compared with the QTcd values of surviving patients (89.1 ± 45.5 to 65 ± 22.9, p = 0.001). The sensitivity of QTcd > 71.5 ms for prediction of mortality was 71% with a specificity of 73% (p = 0.001). We observed a strong correlation between QTcd and ECG score values (r = 0.69, p< 0.001). There was also a correlation between QTcd values and pulmonary artery pressure (PAP) (r = 0.27, p = 0.05).

CONCLUSION

QTcd is significantly increased in high-risk PE patients compared to intermediate and low-risk patients. In addition, QTcd is significantly correlated with ECG score and PAP.

Electrocardiography patterns and the role of the electrocardiography score for risk stratification in acute pulmonary embolism

Background and Objectives

Data on the usefulness of a combination of different electrocardiography (ECG) abnormalities in risk stratification of patients with acute pulmonary embolism (PE) are limited. We thus investigated 12-lead ECG patterns in acute PE to evaluate the role of the ECG score in risk stratification of patients with acute PE.

Subjects and Methods

One hundred twenty-five consecutive patients (63±14 years, 56 men) with acute PE who were admitted to Kyungpook National University Hospital between November 2001 and January 2008 were included. We analyzed ECG patterns and calculated the ECG score in all patients. We evaluated right ventricular systolic pressure (RVSP) (n=75) and RV hypokinesia (n=80) using echocardiography for risk stratification of acute PE patients.

Results

Among several ECG findings, sinus tachycardia and inverted T waves in V_1-4 (39%) were observed most frequently. The mean ECG score and RVSP were 7.36±6.32 and 49±21 mmHg, respectively. The ECG score correlated with RVSP (r=0.277, p=0.016). The patients were divided into two groups {high ECG-score group (n=38): ECG score >12 and low ECG-score group (n=87): ECG score ≤12} based on the ECG score, with the maximum area under the curve. RV hypokinesia was observed more frequently in the high ECG-score group than in the low ECG-score group (p=0.006). Multivariate analysis revealed that a high ECG score was an independent predictor of high RVSP and RV hypokinesia.

Conclusion

Sinus tachycardia and inverted T waves in V_1-4 were commonly observed in acute PE. Moreover, the ECG score is a useful tool in risk stratification of patients with acute PE.

A simple clinical model composed of ECG, shock index, and arterial blood gas analysis for predicting severe pulmonary embolism

BACKGROUND

Objective diagnosis of severe pulmonary embolism (PE) is obligatory because of its considerable mortality.

AIM

To assess the abilities of electrocardiography (ECG) score (sECG) and the newly generated scoring system composed of the scores obtained from arterial blood gas (ABG) analysis and shock index (SI) in addition to sECG in predicting severe PE.

MATERIAL AND METHODS

The degree of pulmonary vascular obstruction (sPVO) and the right ventricular dysfunction (RVD) were determined with spiral computed tomography (CT) in 53 consequent patients with PE. Twelve-lead ECG taken within a day of PE event and ABG values were evaluated according to ECG scoring system and original Geneva system, respectively.

RESULTS

The mean age of patients was 62.6 ± 13.4 years. Right ventricular dysfunction, sPVO ≥ 50%, hypoxemia, and SI were present in 34 (64.2%), 27 (50.9%), 50 (94.3%), and 22 (41.5%) patients, respectively. The mean sECG, 5.9 ± 5.1, was correlated with sPVO, maximum diameter of right ventricle (RV), and right ventricle to left ventricle (RV/LV) ratio (r = .385, r = .415, and r = .329, respectively). The mean newly generated score was 10.9 ± 5.5 and correlated with sPVO, maximum diameter of RV, and RV/LV ratio (r = .394, r = .483, and r = .393, respectively). Receiver operator characteristic (ROC) curve analyses revealed that sECG ≥ 3.5, s (ECG + SI) ≥ 4.5, and s (ECG + SI + ABG) ≥ 9.5 predict the severe PE patients with 70.6%, 61.8%, 58.8% sensitivities and 52.6%, 63.2%, 73.7% specificities, respectively.

CONCLUSION

Adding the scores obtained from SI and ABG to the sECG enhances the specificity of sECG in predicting RVD (+) or severe PE patients, although a lesser degree decreasing in sensitivity may occur.

12-lead ECG findings of pulmonary hypertension occur more frequently in emergency department patients with pulmonary embolism than in patients without pulmonary embolism

STUDY OBJECTIVE

Acute pulmonary embolism can produce abnormalities on ECG that reflect severity of pulmonary hypertension. Early recognition of these findings may alter the estimated pretest probability of pulmonary embolism and prompt more aggressive treatment before hemodynamic instability ensues, but it is first important to test whether these findings are specific to patients with pulmonary embolism. We hypothesize that ECG findings consistent with pulmonary hypertension would be observed more frequently in patients with pulmonary embolism.

METHODS

Secondary analysis of a prospective, observational cohort of emergency department patients who were tested for pulmonary embolism. ECGs were ordered at clinician's discretion and interpreted at presentation.

RESULTS

Six thousand forty-nine patients had an ECG, 354 (5.9%) of whom were diagnosed with pulmonary embolism. The frequency, positive likelihood ratio (LR+) and 95% confidence interval (CI) of each predictor were as follows: S1Q3T3 8.5% with pulmonary embolism versus 3.3% without pulmonary embolism (LR+ 3.7; 95% CI 2.5 to 5.4); nonsinus rhythm, 23.5% versus 16.6% (LR+ 1.4; 95% CI 1.2 to 1.7); inverted T waves in V1 to V2, 14.4% versus 8.1% (LR+ 1.8; 95% CI 1.3 to 2.3); inversion in V1 to V3, 10.5% versus 4.0% (LR+ 2.6; 95% CI 1.9 to 3.6); inversion in V1 to V4, 7.3% versus 2.0% (LR+ 3.7; 95% CI 2.4 to 5.5); incomplete right bundle branch block, 4.8% versus 2.8% (LR+ 1.7; 95% CI 1.0 to 2.7); tachycardia (pulse rate >100 beats/min), 28.8% versus 15.7% (LR+ 1.8; 95% CI 1.5 to 2.2). Likelihood ratios and specificities were similar when patients with previous cardiopulmonary disease were excluded from analysis.

CONCLUSION

Findings of acute pulmonary hypertension were infrequent overall but were observed more frequently in patients with the final diagnosis of pulmonary embolism compared with patients who do not have pulmonary embolism.

Prognostic value of ECG among patients with acute pulmonary embolism and normal blood pressure

OBJECTIVE

To investigate the prognostic value of electrocardiography (ECG) alone or in combination with echocardiography in patients with acute pulmonary embolism and normal blood pressure.

METHODS

Consecutive adult patients presenting to the emergency department at Azienda Ospedaliero-Universitaria Careggi with the first episode of pulmonary embolism were included. Patients with systolic blood pressure less than 100 mm Hg were excluded. ECG and echocardiography were performed within 1 hour from diagnosis and evaluated in a blinded fashion. Right ventricular strain was diagnosed in the presence of one or more of the following ECG findings: complete or incomplete right ventricular branch block, S1Q3T3, and negative T wave in V1-V4. The main outcome measurement was clinical deterioration or death during in-hospital stay. The association of variables with the main outcome was evaluated by multivariate Cox survival analysis.

RESULTS

A total of 386 patients with proved pulmonary embolism were included in the study; 201 patients (52%) had right ventricular dysfunction according to echocardiography, and 130 patients (34%) showed right ventricular strain. Twenty-three patients (6%) had clinical deterioration or died. At multivariate survival analysis, right ventricular strain was associated with adverse outcome (hazard ratio 2.58; 95% confidence interval, 1.05-6.36) independently of echocardiographic findings. Patients with both right ventricular strain and right ventricular dysfunction (26%) showed an 8-fold elevated risk of adverse outcome (hazard ratio 8.47; 95% confidence interval, 2.43-29.47).

CONCLUSION

Right ventricular strain pattern on ECG is associated with adverse short-term outcome and adds incremental prognostic value to echocardiographic evidence of right ventricular dysfunction in patients with acute pulmonary embolism and normal blood pressure.

Electrocardiographic score and short-term outcomes of acute pulmonary embolism

Risk stratification of patients with a diagnosis of acute pulmonary embolism (PE) is crucial in deciding appropriate management. An electrocardiographic (ECG) scoring system may potentially be useful in identifying patients at high risk of increased hospital morbidity and mortality from acute PE. Electrocardiography and echocardiography of 159 patients with a diagnosis of acute PE using ventilation/perfusion scan or spiral computed tomographic scan at 2 Emory-affiliated hospitals were reviewed. The 21-ECG score was compared with the presence or absence of right ventricular (RV) dysfunction and the 2 major end points of complicated in-hospital course or death. ECG score was significantly higher in patients with RV dysfunction (p <0.001) and a complicated in-hospital course (p <0.05). Although the ECG score was higher in nonsurvivors, it was not significantly different. Based on receiver-operator characteristic curves, an ECG score > or =3 could predict RV dysfunction with sensitivity, specificity, and positive and negative predictive values of 76%, 82%, 76%, and 86%, respectively. An ECG score > or =3 could predict a complicated in-hospital course and mortality with sensitivities of 58% and 59%, specificities of 60% and 58%, positive predictive values of 16% and 10%, and negative predictive values of 89% and 95%, respectively. In conclusion, the current 21-ECG scoring system can predict RV dysfunction in patients with acute PE well. However; its ability to predict an adverse in-hospital course is limited. Nevertheless, an ECG score <3 predicts better short-term outcome in these patients.

Management strategies for patients with pulmonary hypertension in the intensive care unit

OBJECTIVE

Pulmonary hypertension may be encountered in the intensive care unit in patients with critical illnesses such as acute respiratory distress syndrome, left ventricular dysfunction, and pulmonary embolism, as well as after cardiothoracic surgery. Pulmonary hypertension also may be encountered in patients with preexisting pulmonary vascular, lung, liver, or cardiac diseases. The intensive care unit management of patients can prove extremely challenging, particularly when they become hemodynamically unstable. The objective of this review is to discuss the pathogenesis and physiology of pulmonary hypertension and the utility of various diagnostic tools, and to provide recommendations regarding the use of vasopressors and pulmonary vasodilators in intensive care.

DATA SOURCES AND EXTRACTION

We undertook a comprehensive review of the literature regarding the management of pulmonary hypertension in the setting of critical illness. We performed a MEDLINE search of articles published from January 1970 to March 2007. Medical subject headings and keywords searched and cross-referenced with each other were: pulmonary hypertension, vasopressor agents, therapeutics, critical illness, intensive care, right ventricular failure, mitral stenosis, prostacyclin, nitric oxide, sildenafil, dopamine, dobutamine, phenylephrine, isoproterenol, and vasopressin. Both human and animal studies related to pulmonary hypertension were reviewed.

CONCLUSIONS

Pulmonary hypertension presents a particular challenge in critically ill patients, because typical therapies such as volume resuscitation and mechanical ventilation may worsen hemodynamics in patients with pulmonary hypertension and right ventricular failure. Patients with decompensated pulmonary hypertension, including those with pulmonary hypertension associated with cardiothoracic surgery, require therapy for right ventricular failure. Very few human studies have addressed the use of vasopressors and pulmonary vasodilators in these patients, but the use of dobutamine, milrinone, inhaled nitric oxide, and intravenous prostacyclin have the greatest support in the literature. Treatment of pulmonary hypertension resulting from critical illness or chronic lung diseases should address the primary cause of hemodynamic deterioration, and pulmonary vasodilators usually are not necessary.

Acute pulmonary embolism: risk stratification in the emergency department

Pulmonary embolism is a common disease associated with a high mortality rate. Death due to pulmonary embolism occurs more commonly in undiagnosed patients before hospital admission or during the initial in-hospital stay. Thus, mortality could be reduced by prompt diagnosis, early prognostic stratification and more intensive treatment in patients with adverse prognosis. Mortality is particularly high in patients with pulmonary embolism presenting with arterial hypotension or cardiogenic shock. In patients with pulmonary embolism and normal blood pressure, a number of clinical features and objective findings have been associated with a high risk of adverse in-hospital outcome. Advanced age and concomitant cardiopulmonary disease are clinical risk factors for in-hospital mortality. The Bburden of thromboembolism, as assessed by lung scan or spiral CT, and right ventricle overload, as assessed by echocardiography and probably spiral CT, have been claimed to be risk factors for in-hospital mortality. Elevated serum levels of troponins have been shown to be associated with right ventricular overload and adverse in-hospital outcomes in patients with pulmonary embolism. Despite the currently available evidence, no definite prognostic value can be assigned to any of the individual risk factors or cluster of them. Large prospective trials should be carried out to validate individual risk factors or clusters of risk factors able to identify patients with acute pulmonary embolism at high risk for in-hospital mortality. These patients could afford the trade-off of an increased risk of side effects related to a more aggressive treatment, such as thrombolysis or surgical or interventional procedures.

Electrocardiography and Wells scoring in predicting the anatomic severity of pulmonary embolism

Pulmonary embolism (PE) is a major health problem associated with a significant morbidity and mortality. Immediate recognition of submassive and massive cases is extremely important in order to commencement of early and appropriate therapy that could be life saving. The aim of this study was to assess the ability of two scoring systems, electrocardiography (ECG) and simplified Wells (sWells) clinical scorings in predicting anatomic severity of PE. Hence, ECG and sWells scorings were combined in order to test the hypothesis if this new scoring does enhance the prediction of severity. Fifty six patients with proven PE with high (50 patients) and moderate (six patients)-probability of ventilation/perfusion (V/Q) scan were retrospectively studied. Baseline ECGs were analysed by two independent observers in order to constitute ECG scorings. Baseline sWells scores were also calculated. Anatomic severity of PE was calculated by scintigraphically and categorized into mild (<50% perfusion defect) (group 1), and severe (50% perfusion defect) (group 2) diseases. The mean of ECG scores, sWells scores and the combined scores were 5.23+/-3.42 and 5.85+/-3.82; 6.60+/-1.88 and 7.03+/-2.40; and 10.73+/-3.60 and 11.60+/-4.32 in groups 1 and 2, respectively (p>0.05). An ECG score of 6.5 predicted severe disease (perfusion defect 50%) with a sensitivity of 41.7% and a specificity of 82%). sWells and combined scores did not provide better sensitivity or specificity values based on ROC curve analysis. Our results indicated that ECG scoring could be valuable test in predicting anatomic severity of PE, adding sWells scoring to ECG scoring did not provide any beneficial effect.

Surrogate markers for adverse outcomes in normotensive patients with pulmonary embolism*

BACKGROUND

Although echocardiography has proven utility in risk stratifying normotensive patients with pulmonary embolism, echocardiography is not always available.

OBJECTIVE

Test if a novel panel consisting of pulse oximetry, 12-lead electrocardiography, and serum troponin T would have prognostic equivalence to echocardiography and to examine the prognostic performance of age, previous cardiopulmonary disease, D-dimer, brain natriuretic peptide, and percentage of pulmonary vascular occlusion on chest computed tomography.

DESIGN

Prospective cohort study.

PATIENTS AND SETTING

Normotensive (systolic blood pressure of >100 mm Hg) emergency department and hospital inpatients with diagnosed pulmonary embolism who underwent cardiologist-interpreted echocardiography and other measurements within 15 hrs of anticoagulation.

MEASUREMENTS AND MAIN RESULTS

End points were in-hospital circulatory shock or intubation, or death, recurrent pulmonary embolism, or severe cardiopulmonary disability (defined as echocardiographic evidence of severe right ventricular dysfunction with New York Heart Association class III dyspnea or 6-min walk test of <330 m) at 6-month follow-up. The two-one-sided test tested the hypothesis of equivalence with one-tailed alpha = 0.05 and Delta = 5%. Of 200 patients enrolled, data were complete for 181 (88%); 51 of 181 patients (28%) had an adverse outcome, including in-hospital complication (n = 18), death (n = 11), recurrent pulmonary embolism (n = 2), or cardiopulmonary disability (n = 20). Right ventricular dysfunction on initial echocardiogram was 61% sensitive (95% confidence interval, 46-74%) and 57% specific (48-66%). The panel was 71% sensitive (56-83%) and 62% specific (53-71%). The two-one-sided procedure demonstrated superiority of the panel to echocardiography for both sensitivity and noninferiority for specificity. No other biomarker demonstrated equivalence, noninferiority, or superiority for sensitivity and specificity.

CONCLUSION

Normotensive patients with pulmonary embolism have a high rate of severe adverse outcomes during 6-month follow-up. A panel of three widely available tests can be used to risk stratify patients with pulmonary embolism when formal echocardiography is not available.

Diagnostic assessment of deep vein thrombosis and pulmonary embolism

Venous thromboembolism (VTE) is a common disorder that can lead to substantial morbidity and mortality through the clinical manifestations of deep vein thrombosis (DVT) and pulmonary embolism (PE). Although rapid diagnosis and treatment are critical in preventing PE, mortality and major morbidity due to conditions such as postthrombotic syndrome may complicate the differential diagnosis of VTE. The clinical symptoms associated with DVT are neither sensitive nor specific and can be indicative of a wide range of diagnoses. Because imaging studies can be expensive and are sometimes inconclusive, they should be used judiciously in patients with highly suspected VTE. This review offers a clinical perspective on the accurate, routine diagnosis of VTE, including an overview of common clinical signs and symptoms, as well as the advantages and drawbacks of available diagnostic strategies.