QT dispersion in patients with pulmonary embolism

Differentiating electrocardiographic indications of massive and submassive pulmonary embolism: A cross-sectional study in Southern Iran from 2015 to 2020

BACKGROUND

Although using electrocardiogram (ECG) for pulmonary embolism (PE) risk stratification has shown mixed results, it is currently used as supplementary evidence in risk stratification. This cross-sectional study aimed to assess and compare ECG findings of massive and submassive PE versus segmental PE.

METHODS

This cross-sectional study included 250 hospitalized patients with a confirmed diagnosis of acute PE from 2015 to 2020 in Southern Iran. Demographic variables, clinical data, troponin levels, on-admission ECG findings, echocardiography findings, and ECG findings 24 h after receiving anticoagulants or thrombolytics were extracted.

RESULTS

Patients diagnosed with submassive or massive PE exhibited significantly higher rates of right axis deviation (p = .010), abnormal ST segment (p < .0001), S1Q3T3 pattern (p < .0001), inverted T wave in leads V1-V3 (p < .0001), inverted T wave in leads V4-V6 (p < .0001), and inverted T wave in leads V1-V6 (p < .0001). In a multivariable model, inverted T wave in leads V1-V3, inverted T wave in leads V4-V6, pulse rate, and positive troponin test were the statistically independent variables for predicting submassive or massive PE. Furthermore, inverted T wave in leads V1-V3 (sensitivity: 85%, specificity: 95%, accuracy: 93%, AUC: 0.902) and troponin levels (sensitivity: 72%, specificity: 86%, accuracy: 83%, AUC: 0.792) demonstrated the best diagnostic test performance for discriminating submassive or massive PE from segmental PE.

CONCLUSION

In addition to clinical rules, ECG can serve as an ancillary tool for assessing more invasive testing and earlier aggressive treatments among patients with PE, as it can provide valuable information for the diagnosis and risk stratification of submassive or massive PE.

Effect of pulmonary embolism location on electrocardiological parameters

OBJECTIVE

Pulmonary thromboembolism is a disease with high morbidity and mortality. Various changes occur on the electrocardiogram secondary to pulmonary thromboembolism. The objective of this study was to investigate variations in QT dispersion, Tpeak-Tend duration, and Tpeak-Tend/QT ratio in relation to pulmonary thromboembolism localization and their impacts on 30-day mortality.

METHODS

This study was carried out in a tertiary emergency medicine clinic between December 1, 2019 and November 30, 2020. We evaluated correlations between radiological outcomes of patients, QT dispersions, T-wave dispersions, Tpeak-Tend durations, and Tpeak-Tend/QT ratios. We sought statistically significant disparities between these values, considering the presence or localization of pulmonary thromboembolism. The 30-day mortality in pulmonary thromboembolism-diagnosed patients was reassessed.

RESULTS

Electrocardiogramfindings revealed that T-wave dispersion (p<0.001), Tpeak-Tend duration (p=0.034), and Tpeak-Tend/corrected QT ratio (p=0.003) were lower in patients than controls. Conversely, QT dispersion (p=0.005) and corrected QT dispersion (p<0.001) were higher in patients.

CONCLUSION

Electrocardiogram findings such as T-wave dispersion, QT duration, Tpeak-Tend time, and Tpeak-Tend/corrected QT ratio can detect pulmonary thromboembolism. More studies with larger cohorts are required to further understand the role of QT and corrected QT dispersion in pulmonary thromboembolism patient mortality.

Dilemmas in the Choice of Adequate Therapeutic Treatment in Patients with Acute Pulmonary Embolism—From Modern Recommendations to Clinical Application

Pulmonary thromboembolism is a very common cardiovascular disease, with a high mortality rate. Despite the clear guidelines, this disease still represents a great challenge both in diagnosis and treatment. The heterogeneous clinical picture, often without pathognomonic signs and symptoms, represents a huge differential diagnostic problem even for experienced doctors. The decisions surrounding this therapeutic regimen also represent a major dilemma in the group of patients who are hemodynamically stable at initial presentation and have signs of right ventricular (RV) dysfunction proven by echocardiography and positive biomarker values (pulmonary embolism of intermediate–high risk). Studies have shown conflicting results about the benefit of using fibrinolytic therapy in this group of patients until hemodynamic decompensation, due to the risk of major bleeding. The latest recommendations give preference to new oral anticoagulants (NOACs) compared to vitamin K antagonists (VKA), except for certain categories of patients (patients with antiphospholipid syndrome, mechanical valves, pregnancy). When using oral anticoagulant therapy, special attention should be paid to drug–drug interactions, which can lead to many complications, even to the death of the patient. Special population groups such as pregnant women, obese patients, patients with antiphospholipid syndrome and the incidence of cancer represent a great therapeutic challenge in the application of anticoagulant therapy. In these patients, not only must the effectiveness of the drugs be taken into account, but great attention must be paid to their safety and possible side effects, which is why a multidisciplinary approach is emphasized in order to provide the best therapeutic option.

Index of cardiac-electrophysiological balance and the effects of thrombolytic therapy on the electrocardiogram of patients with pulmonary embolism

OBJECTIVE

Different parameters on electrocardiograms (ECG) have been investigated to predict arrhythmia and mortality in patients with acute pulmonary embolism (APE). The acute effect of thrombolytic therapy (TT) on these parameters has not been investigated yet.

METHODS

We examined the data of 83 patients who were evaluated as high-risk APE and discharged from the hospital after TT. First, the high-risk APE patients' ECGs were compared with healthy control subjects (n = 55). After their admission and 24 hours later, the ECGs of patients with APE were compared. Heart rate, P-wave morphology, QRS duration, QT distance, Tp-e, and the index of cardiac electrophysiological balance (iCEB) were analyzed.

RESULTS

Although P maximum was not different between the groups' ECGs, heart rate, QT, QTc (corrected QT) interval, Tp-e intervals, Tp-e/QT ratio, and P wave dispersion were significantly higher in the APE group ( P values < 0.031). iCEB or iCEBc (corrected iCEB) values were lower in APE group ( P < 0.001). After TT, we determined a decrease in heart rate, Tp-e interval, and Tp-e/QT ratio ( P < 0.001). Although we detected a decrease in the QT and QTc interval and QT dispersion (QTd), QTd had no statistical significance (respectively P -value 0.013, 0.029, and 0.096). The iCEB and iCEBc levels were lower after TT ( P -value was 0.035 and 0.044 respectively).

CONCLUSION

The QT, QTc, Tp-e interval, Tp-e/QTc ratio, iCEB, and iCEBc values significantly decreased after TT. It may be thought that effective TT causes partial improvement in ventricular repolarization in an early period.

The value of electrocardiography in prognosticating clinical deterioration and mortality in acute pulmonary embolism: A systematic review and meta-analysis

The role of electrocardiography (ECG) in prognosticating pulmonary embolism (PE) is increasingly recognized. ECG is quickly interpretable, noninvasive, inexpensive, and available in remote areas. We hypothesized that ECG can provide useful information about PE prognostication. We searched MEDLINE, EMBASE, Google Scholar, Web of Science, abstracts, conference proceedings, and reference lists through February 2017. Eligible studies used ECG to prognosticate for the main outcomes of death and clinical deterioration or escalation of therapy. Two authors independently selected studies; disagreement was resolved by consensus. Ad hoc piloted forms were used to extract data and assess risk of bias. We used a random-effects model to pool relevant data in meta-analysis with odds ratios (ORs) and 95% confidence intervals (CIs); all other data were synthesized qualitatively. Statistical heterogeneity was assessed using the I ² value. We included 39 studies (9198 patients) in the systematic review. There was agreement in study selection (κ: 0.91, 95% CI: 0.86-0.96). Most studies were retrospective; some did not appropriately control for confounders. ECG signs that were good predictors of a negative outcome included S1Q3T3 (OR: 3.38, 95% CI: 2.46-4.66, P < 0.001), complete right bundle branch block (OR: 3.90, 95% CI: 2.46-6.20, P < 0.001), T-wave inversion (OR: 1.62, 95% CI: 1.19-2.21, P = 0.002), right axis deviation (OR: 3.24, 95% CI: 1.86-5.64, P < 0.001), and atrial fibrillation (OR: 1.96, 95% CI: 1.45-2.67, P < 0.001) for in-hospital mortality. Several ischemic patterns also were significantly predictive. Our conclusion is that ECG is potentially valuable in prognostication of acute PE.

The value of electrocardiographic abnormalities in the prognosis of pulmonary embolism: a consensus paper

Electrocardiographic (ECG) abnormalities in the setting of acute pulmonary embolism (PE) are being increasingly characterized and mounting evidence suggests that ECG plays a valuable role in prognostication for PE. We review the historical 21-point ECG prognostic score for the severity of PE and examine the updated evidence surrounding the utility of ECG abnormalities in prognostication for severity of acute PE. We performed a literature search of MEDLINE, EMBASE, and PubMed up to February 2015. Article titles and abstracts were screened, and articles were included if they were observational studies that used a surface 12-lead ECG as the instrument for measurement, a diagnosis of PE was confirmed by imaging, arteriography or autopsy, and analysis of prognostic outcomes was performed. Thirty-six articles met our inclusion criteria. We review the prognostic value of ECG abnormalities included in the 21-point ECG score, including new evidence that has arisen since the time of its publication. We also discuss the potential prognostic value of several ECG abnormalities with newly identified prognostic value in the setting of acute PE.

Predictors of early death in patients with acute pulmonary embolism

AIM

We aimed to determine the predictors of early death in the course of acute pulmonary embolism (APE).

MATERIALS AND METHODS

We included 206 patients who had been admitted to our hospital between January 2011 and April 2013 with the diagnosis of APE. We derived a new model including corrected QT interval dispersion (QTcd) and P wave dispersion (Pd), echocardiographic findings, laboratory markers, and blood cell count indices to predict early death in patients with APE.

RESULTS

Thirty patients (14.5%) died; 176 patients (85.5%) lived after diagnosis of APE. Logistic regression (LR) analysis found that troponin I (odds ratio [OR], 1.084 [95% confidence interval {CI}, 1.009-1.165]), creatinine (OR, 4.153 [95% CI, 1.375-12.541]), mean platelet volume (OR, 1.991 [95% CI, 1.230-3.223]), neutrophil to lymphocyte ratio (NLR) (OR, 1.079 [95% CI, 1.005-1.160]), QTcd (OR, 1.084 [95% CI, 1.043-1.127]), Pd (OR, 1.049 [95% CI, 1.004-1.096]) were associated with early death in APE. New LR model (area under the curve [AUC], 0.970) performed better than the simplified pulmonary embolism severity index (sPESI) score (AUC, 0.859) in predicting early death in APE (P=.021). The predictivity of the sPESI score significantly improved after its single combination with creatinine, QTcd, or troponin I. When the combined model was constructed together with these 6 independent variables and sPESI score, stepwise LR model automatically excluded Pd and NLR, and the AUC from the rest of the combined model was 0.976, which is significantly different from the AUC of sPESI (0.859) (P=.0031).

CONCLUSIONS

Creatinine, troponin I, and QTcd significantly improves sPESI score. A new model with troponin I, creatinine, mean platelet volume, NLR, QTcd, and Pd seems to have greater prognostic power than the sPESI scoring system.