Appearance of right bundle branch block in electrocardiograms of patients with pulmonary embolism as a marker for obstruction of the main pulmonary trunk

doi:10.1054/jelc.2001.25132

Journal of Electrocardiology

Volume 34, Issue 3, July 2001, Pages 185-188

https://doi.org/10.1054/jelc.2001.25132 Get rights and content

Abstract

A number of changes occur in the electrocardiogram (ECG) of pulmonary embolism. This article deals with the diagnostic value of the newly emerged right bundle branch block (RBBB) as a manifestation of acute right ventricular overload. A certain correlation between the extent of obstruction of the pulmonary artery and the appearance of RBBB is established through dynamic monitoring of the ECG. Fifty cases of dissectionally proven pulmonary embolism are observed, in 20 of which massive trunk obstruction had taken place, and in the remaining 30 peripheral embolism in the pulmonary artery was established. With 80% of the trunk embolism patients (16 cases), a newly emerged RBBB was detected in their ECG, and with the remaining 20% (4 cases), ST-segment depression and T-wave inversion in leads V₁-V₄ were observed as well as right axis deviation. S₁Q₃T₃ syndrome was detected among 60% (12 cases) of trunk embolism patients. In none of the peripheral embolism cases was RBBB in the ECG registered. Thus, its appearance on dynamic monitoring of the ECG of pulmonary embolism patients is a significant sign of the probability of massive obstruction of the main pulmonary trunk.

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ST-segment elevations with bradycardia in inferior leads: Acute pulmonary embolism
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Prognostic role of serial electrocardiographic changes in patients with acute pulmonary embolism. Data from the Italian Pulmonary Embolism Registry
2022, Thrombosis Research
Citation Excerpt :
Moreover, the observed resolution pattern of ECG abnormalities clearly reflects the prognostic significance of different ECG signs in acute PE patients. Indeed, both S1Q3T3 and RBBB have been already associated with the thrombotic burden involving the main pulmonary artery trunk [8,19] and represent an indirect sign of right ventricular enlargement and overload, which are per se independent risk factors of 30-day mortality [20,21]. When the ECG signs constituting the RVS definition were considered separately, only the persistence of RBBB and NTWs in V1-V4 leads resulted significantly associated to higher risk of 30-day mortality (HRa: 2.48, 95 % CI: 1.03–5.09, p = 0.002, for RBBB and HRa: 1.63, 95 % CI: 1.04–2.55, p < 0.0001 for NTWs in V1-V4 leads).
The prognostic role of serial electrocardiographic modifications in patients with acute pulmonary embolism (PE) have been poorly investigated. We evaluate the electrocardiographic changes in PE patients during their hospitalization and the prognostic role of such ECG modifications in respect to 30-day mortality in patients enrolled in the Italian Pulmonary Embolism Registry (IPER).
Subjects enrolled into the IPER (September 2006–August 2010) were stratified according to their hemodynamic status, as high- (hemodynamically unstable) and non-high-risk (hemodynamically stable) patients. ECG features were analysed at three fixed time points: at presentation, on day 3 and at discharge.
Overall, 687 patients (286 males, mean age 69.0 ± 15.5 years) were included in the study. Among these, 71 (10.3 %) were at high-risk. In these patients, multivariate analysis revealed that the persistence of right ventricular strain (RVS) after three days from hospitalization was a predictor of 30-day mortality [HRa: 2.78 (95 % CI: 1.05–7.31, p = 0.003)]. Moreover, the persistence of right bundle branch block (RBBB) [HRa: 2. 48 (95 % CI: 1.03–5.09, p = 0.002)], negative T waves in V1-V4 (NTWs) [HRa: 1.63 (95 % CI: 1.04–2.55), p < 0.0001] and qR complex in lead V1 [HRa: HR: 5.44, (95 % CI: 3.22–9.44, p < 0.0001)] were associated with an increased risk of 30-day mortality. When RBBB, NTWs and qR complex in V1 lead were present concomitantly, the 30-day risk of death resulted significantly higher [HR: 12.5 (95 % CI: 3.39–46.4,) p < 0.0001].
Persistence of RBBB, NTWs, and qR pattern in V1 lead at day 3 of hospitalization are independent prognostic factors of death within 30 days in high-risk acute PE patients. The prognostic power of any single ECG abnormality is lower compared to the combination of the three ECG variables.
Electrocardiographic Findings in Coronavirus Disease-19: Insights on Mortality and Underlying Myocardial Processes
2020, Journal of Cardiac Failure
Citation Excerpt :
Given the high rate of respiratory failure in a significant proportion of infected individuals, cardiac dysfunction secondary to increased afterload on the right ventricle (referred to as acute cor pulmonale) is not unexpected. Although ECG findings are insensitive for the detection of acute cor pulmonale,17 RBBB has been attributed to acute RV overload and distention in multiple studies of acute pulmonary embolism, with a higher frequency noted in cases with larger clot burdens.18 In a recent study, RV dysfunction was associated with a higher risk of mortality in patients with COVID-19, independent of all other echocardiographic parameters.19
Coronavirus disease 2019 (COVID-19) is a respiratory syndrome with high rates of mortality, and there is a need for easily obtainable markers to provide prognostic information. We sought to determine whether the electrocardiogram (ECG) on hospital presentation provides prognostic information, specifically related to death.
We performed a retrospective cohort study in patients with COVID-19 who had an ECG at or near hospital admission. Clinical characteristics and ECG variables were manually abstracted from the electronic health record and first ECG. Our primary outcome was death.
756 patients who presented to a large New York City teaching hospital with COVID-19 who underwent an ECG. The mean age was 63.3 ± 16 years, 37% were women, 61% of patients were nonwhite, and 57% had hypertension; 90 (11.9%) died. In a multivariable logistic regression that included age, ECG, and clinical characteristics, the presence of one or more atrial premature contractions (odds ratio [OR] 2.57, 95% confidence interval [CI] 1.23–5.36, P = .01), a right bundle branch block or intraventricular block (OR 2.61, 95% CI 1.32–5.18, P = .002), ischemic T-wave inversion (OR 3.49, 95% CI 1.56–7.80, P = .002), and nonspecific repolarization (OR 2.31, 95% CI 1.27–4.21, P = .006) increased the odds of death. ST elevation was rare (n = 5 [0.7%]).
We found that patients with ECG findings of both left-sided heart disease (atrial premature contractions, intraventricular block, repolarization abnormalities) and right-sided disease (right bundle branch block) have higher odds of death. ST elevation at presentation was rare.
Pulmonary embolism and complete atrioventricular block
2018, Design Studies
Le bloc auriculoventriculaire (BAV) complet est une complication peu commune de l’embolie pulmonaire. Nous décrivons le cas d’un patient noir Africain âgé de 42 ans, admis aux urgences de l’institut de cardiologie d’Abidjan pour l’exploration d’une dyspnée de survenue brutale et d’une hémoptysie. L’électrocardiogramme retrouvait un BAV de troisième degré. L’angio-TDM thoracique mettait en évidence une embolie pulmonaire proximale droite. Nous rapportons à notre connaissance la première description d’une embolie pulmonaire compliquée d’un BAV complet en Afrique subsaharienne. En cas d’embolie pulmonaire, une surveillance étroite clinique et électrocardiographique est nécessaire afin d’identifier rapidement cette entité rare qui pourrait grever le pronostic des patients.
Complete atrioventricular block is a rare complication of pulmonary embolism. We describe the case of a black African patient, aged 42 years, who presented to the emergency department of Abidjan Heart Institute for sudden onset dyspnea and hemoptysis. ECG revealed a third degree atrioventricular block. Computed tomographic angiography showed proximal pulmonary embolism of the right main pulmonary artery. To our knowledge, this is the first case of complete atrioventricular block in pulmonary embolism in Sub-Saharan Africa. In case of pulmonary embolism, clinical and electrocardiographic monitoring is necessary in order to identify this uncommon and potentially serious outcome.
Right bundle branch block and S<inf>I</inf>Q<inf>III</inf>-type patterns for risk stratification in acute pulmonary embolism
2016, Journal of Electrocardiology
Citation Excerpt :
This ECG is in first line used to exclude acute ST-segment elevation myocardial infarction and arrhythmias [6,7], but is also an important diagnostic tool in PE [1]. Beside these quoted limitations in respect to ECG as a primary diagnostic tool in acute PE, a number of studies reported about ECG alterations predicting RVD as well as poorer prognosis [1,2,8]. Especially the development of right bundle branch block (RBBB) and SIQIII-type patterns in acute PE events seems to be connected with poorer outcome and RV overload [2,8–10].
Risk stratification in acute pulmonary embolism (PE) is crucial for identification of patients with poor prognosis. We aimed to investigate the ECG alterations of right bundle branch block (RBBB) and S_IQ_III-type patterns for risk stratification in acute PE.
Retrospective analysis of PE patients, treated in the Internal Medicine Department, was performed. Patients with RBBB and/or S_IQ_III-type were compared with those without both patterns. Logistic regression models for association between these ECG alterations and respectively right ventricular dysfunction (RVD), high-risk PE status and myocardial injury were computed.
175 patients were included for this retrospective analysis. Total study sample comprised 37 PE patients (21.1%) with RBBB and/or S_IQ_III-type patterns and 138 PE patients (78.9%) without both signs.
Heart rate (97.4 ± 17.2 vs. 93.2 ± 26.8/min, P = 0.021), cardiac troponin I values (0.19 ± 0.38 vs. 0.11 ± 0.24, P = 0.003) and percentage of patients with RVD (83.9% vs. 52.7%, P = 0.005) were significantly higher in PE patients with RBBB and/or S_IQ_III-type patterns compared to PE patients without both ECG alterations.
Multi-variate logistic regression models adjusted for age and gender revealed significant associations between RBBB and RVD (OR3.942, 95% CI1.054–14.747, P = 0.042) and between S_IQ_III-type patterns and RVD (OR5.667, 95% CI1.144–28.071, P = 0.034). The association between RBBB and cardiac injury (cTnI > 0.4 ng/ml) (OR2.531, 95% CI 0.973–6.583, P = 0.06) showed a borderline significance, while the association between S_IQ_III-type patterns and cardiac injury was significant (OR3.956, 95% CI1.309–11.947, P = 0.015).
RBBB and S_IQ_III-type patterns were both associated with RV overload and cardiac injury. RBBB and S_IQ_III-type patterns were connected with 3.9-fold and 5.7-fold elevated risk of RVD, respectively.
The electrocardiographic characteristics of an acute embolism in the pulmonary trunk and the main pulmonary arteries
2016, American Journal of Emergency Medicine
Citation Excerpt :
Right bundle-branch block in cases of PE is usually temporary, and RBBB has been reported as characteristic of RV pressure overload secondary to massive acute PE [7,8]. Petrov [9] surmised that new-onset RBBB is a sign of complete occlusion of the pulmonary trunk. Our study showed that patients suffering from either a pulmonary artery trunk or an MPA embolism experience a higher incidence of RBBB (P = .0002).
Pulmonary embolism (PE) is a common cardiovascular disease that can be easily missed or misdiagnosed. Electrocardiogram (ECG) is valuable in making early diagnoses and performing risk stratification with regard to acute PE.
A total of 147 hospitalized patients diagnosed with acute PE were enrolled in this study and divided into the following 2 groups: main pulmonary artery trunk or main pulmonary artery (MPA) embolism and lobar artery or remote branch embolism. Electrocardiographic abnormalities associated with acute PE were subsequently identified.
Electrocardiographic abnormalities were significantly different between the pulmonary trunk/MPA embolism group and the lobar artery/remote branch embolism group. The incidence of pulmonary trunk/MPA emboli was significantly related to the number of ECG abnormalities (t = − 7.086, P = 5.556e-11). Furthermore, the number of ECG abnormalities noted among patients with pulmonary trunk/MPA emboli was 5.276 times greater than the number observed among the lobar artery/remote branch embolism group (P < .001, 95% confidence interval = − 6.57 to 3.97). The risk of either moderate or severe right ventricular hypertrophy was increased by 16.18% among patients with either pulmonary trunk or MPA emboli compared with patients with either lobar artery or remote branch emboli (P < .001, 95% confidence interval = − 2.76 to 0.876). The correct classification rate was as high as 92.3% when ECG was used to classify the prognosis of PE patients.
The number of ECG abnormalities and the degree of right ventricular hypertrophy as determined via ECG can be used to assess the probability of developing a PE in the pulmonary trunk and MPA. Furthermore, ECGs can assist clinicians with risk stratification.

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^☆: Reprint requests: Daniel Bogdanov Petrov, MD, Clinic of Emergency Cardiology and Acute Internal Diseases, Pirogov Emergency Medical Institute, 21 Macedonia Blvd, Sofia 1606, Bulgaria.

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Appearance of right bundle branch block in electrocardiograms of patients with pulmonary embolism as a marker for obstruction of the main pulmonary trunk☆

Abstract

Chest

Chest

Am J Cardiol

Chest

Int J Cardiol