Chest
Volume 120, Issue 2, August 2001, Pages 474-481
Journal home page for Chest

Clinical Investigations
Cardiology
Assessment of Cardiac Stress From Massive Pulmonary Embolism With 12-Lead ECG

https://doi.org/10.1378/chest.120.2.474Get rights and content

Background

Massive pulmonary embolism (PE) that causes severe pulmonary hypertension can produce specific ECG abnormalities. We hypothesized that an ECG scoring system would vary in proportion to the severity of pulmonary hypertension and would help to distinguish patients with massive PE from patients with smaller PE and those without PE.

Methods

A 21-point ECG scoring system was derived (relative weights in parentheses): sinus tachycardia (2), incomplete right bundle branch block (2), complete right bundle branch block (3), T-wave inversion in leads V1 through V4 (0 to 12), S wave in lead I (0), Q wave in lead III (1), inverted T in lead III (1), and entire S1Q3T3 complex (2). ECGs obtained within 48 h prior to pulmonary arteriography were located for 60 patients (26 positive for PE, 34 negative for PE) and for 25 patients with fatal PE.

Results

Interobserver agreement (11 readers) for ECG score was good (Spearman r = 0.74). The ECG score showed significant positive relationship to systolic pulmonary arterial pressure (sPAP) in patients with PE (r = 0.387, p < 0.001), whereas no significant relationship was seen in patients without PE (r = − 0.08, p = 0.122). When patients were grouped by severity of pulmonary hypertension (low, moderate, severe), only patients with severe pulmonary hypertension from PE had a significantly higher ECG score (mean, 5.8 ± 4.9). At a cutoff of 10 points, the ECG score was 23.5% (95% confidence interval [CI], 16 to 31%) sensitive and 97.7% (95% CI, 96 to 99%) specific for the recognition of severe pulmonary hypertension (sPAP > 50 mm Hg) secondary to PE. In 25 patients with fatal PE, the ECG score was 9.5 ± 5.2.

Conclusions

The derived ECG score increases with severity of pulmonary hypertension from PE, and a score≥ 10 is highly suggestive of severe pulmonary hypertension from PE.

Section snippets

Materials and Methods

To derive the ECG scoring system, electronic databases (MEDLINE, EMBASE) were searched using the exploded key words “pulmonary embolism” and “electrocardiography” from 1966 to September 2000. Original full-length clinical studies were reviewed and were examined for reports that included the frequency of ECG findings associated with PE, together with data to assess the severity of PE based on results of pulmonary angiography, echocardiography, or autopsy.12346789 Studies were then limited to

Results

For group A, 60 cases were identified. Fifty-eight patients underwent a V˙/ Q˙ scan performed prior to the pulmonary angiography. Prior V˙/ Q˙ scans were read as low probability for PE in 10 patients, intermediate probability in 38 patients, indeterminate probability in 7 patients, and high probability in 3 patients. The mean ± SD time after symptom onset to the time of the ECG used for scoring was 27.5 ± 48 h. Six patients had symptoms that began > 1 week prior to the first

Discussion

This study demonstrates a positive relationship between an ECG scoring system and the severity of pulmonary arterial pressure in subjects with PE demonstrated on pulmonary angiography. The 21-point ECG scoring system was derived from previous work that demonstrated the association of each element of the scoring system with pulmonary hypertension from PE, including increased heart rate27; impairment in right-sided cardiac conduction, manifested as various degrees of right bundle branch block367;

Conclusion

Massive PE causes specific abnormalities on ECG that can be quantitated by an explicit scoring system. Massive PE causes a significant increase in the derived ECG score compared to that in patients without massive PE.

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1

Dr. Daniel is currently at the Bowman-Gray School of Medicine, Dept of Internal Medicine, Wake Forest University, Winston-Salem, NC.

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