Korean Circ J.  2010 Oct;40(10):499-506. 10.4070/kcj.2010.40.10.499.

Electrocardiography Patterns and the Role of the Electrocardiography Score for Risk Stratification in Acute Pulmonary Embolism

• Ryu HM
• Lee JH
• Kwon YS
• Lee SH
• Bae MH
• Lee JH
• Yang DH
• Park HS
• Cho Y
• Chae SC
• Jun JE
• Park WH

• KMID: 1826138
• DOI: http://doi.org/10.4070/kcj.2010.40.10.499

Abstract

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 < or =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.

Keyword

Pulmonary embolism; Electrocardiography; Right ventricle; Systolic pressure

MeSH Terms

Blood Pressure
Echocardiography
Electrocardiography
Heart Ventricles
Humans
Hypokinesia
Multivariate Analysis
Pulmonary Embolism
Tachycardia, Sinus

Figure

• 

  Fig. 1 Correlations between right ventricular systolic pressure (RVSP) and the following: R/S ratio in lead I (A), T wave amplitude in lead II (B), T wave amplitude in lead V4 (C), and ECG score (D). There were inverse correlations between RVSP and the R/S ratio in lead I (A) (r=-0.308, p=0.019), T wave amplitude in lead II (B) (r=-0.259, p=0.025), and T wave amplitude in lead V4 (C) (r=-0.227, p=0.050). There was a positive correlation between RVSP and ECG score (D) (r=0.277, p=0.016).

• 

  Fig. 2 Receiver operating characteristics (ROC) curve predicting right ventricular systolic pressure. The area under the curve (AUC) was 0.68 {95% confidence interval (CI)=0.56-0.81} at the point of an ECG score of 12, where sensitivity was 60% and specificity was 77%.

Reference

1. Kosuge M, Kimura K, Ishikawa T, et al. Prognostic significance of inverted T waves in patients with acute pulmonary embolism. Circ J. 2006. 70:750–755.

2. Yoon NS, Cho JG, Park HW, et al. Usefulness of the 12-lead electrocardiography in the diagnosis and evaluation of severity of pulmonary thromboembolism. Korean Circ J. 2005. 35:389–395.

3. Daniel KR, Courtney DM, Kline JA. Assessment of cardiac stress from massive pulmonary embolism with 12-lead ECG. Chest. 2001. 120:474–481.

4. McQuillan BM, Picard MH, Leavitt M, Weyman AE. Clinical correlates and reference intervals for pulmonary artery systolic pressure among echocardiographically normal subjects. Circulation. 2001. 104:2797–2802.

5. Konstantinides S, Geibel A, Heusel G, Heinrich F, Kasper W. Heparin plus alteplase compared with heparin alone in patients with submassive pulmonary embolism. N Engl J Med. 2002. 347:1143–1150.

6. Stein PD, Alshabkhoun S, Hawkins HF, Hyland JW, Jarrett CE. Right coronary blood flow in acute pulmonary embolism. Am Heart J. 1969. 77:356–362.

7. Yoshinaga T, Ikeda S, Shikuwa M, Miyahara Y, Kohno S. Relationship between ECG findings and pulmonary artery pressure in patients with acute massive pulmonary thromboembolism. Circ J. 2003. 67:229–232.

8. Tayama E, Ouchida M, Teshima H, et al. Treatment of acute massive/submassive pulmonary embolism. Circ J. 2002. 66:479–483.

9. Cutforth RH, Oram S. The electrocardiogram in pulmonary embolism. Br Heart J. 1958. 20:41–60.

10. Sreeram N, Cheriex EC, Smeets JL, Gorgels AP, Wellens HJ. Value of the 12-lead electrocardiogram at hospital admission in the diagnosis of pulmonary embolism. Am J Cardiol. 1994. 73:298–303.

11. Iles S, Le Heron CJ, Davies G, Turner JG, Beckert LE. ECG score predicts those with the greatest percentage of perfusion defects due to acute pulmonary thromboembolic disease. Chest. 2004. 125:1651–1656.

12. Kim SE, Park DG, Choi HH, et al. The best predictor for right ventricular dysfunction in acute pulmonary embolism: comparison between electrocardiography and biomarkers. Korean Circ J. 2009. 39:378–381.

13. Chung T, Emmett L, Khoury V, et al. Atrial and ventricular echocardiographic correlates of the extent of pulmonary embolism in the elderly. J Am Soc Echocardiogr. 2006. 19:347–353.

14. Toosi MS, Merlino JD, Leeper KV. Prognostic value of the shock index along with transthoracic echocardiography in risk stratification of patients with acute pulmonary embolism. Am J Cardiol. 2008. 101:700–705.

15. Grewal J, McKelvie RS, Persson H, et al. Usefulness of N-terminal pro-brain natriuretic peptide and brain natriuretic peptide to predict cardiovascular outcomes in patients with heart failure and preserved left ventricular ejection fraction. Am J Cardiol. 2008. 102:733–737.

16. Bibbins-Domingo K, Gupta R, Na B, Wu AH, Schiller NB, Whooley MA. N-terminal fragment of the prohormone brain-type natriuretic peptide (NT-proBNP), cardiovascular events, and mortality in patients with stable coronary heart disease. JAMA. 2007. 297:169–176.

17. Coutance G, Le Page O, Lo T, Hamon M. Prognostic value of brain natriuretic peptide in acute pulmonary embolism. Crit Care. 2008. 12:R109.

18. ten Wolde M, Tulevski II, Mulder JW, et al. Brain natriuretic peptide as a predictor of adverse outcome in patients with pulmonary embolism. Circulation. 2003. 107:2082–2084.