Correlation between ST-segment elevation and negative T waves in the precordial leads in acute pulmonary embolism: insights into serial electrocardiogram changes

Comparative study on electrocardiograms and serological examinations of acute pulmonary embolism and acute non-ST elevation myocardial infarction

BACKGROUND

The aim of this study was to investigate the value of electrocardiograms (ECGs) and serological examinations in the differential diagnosis of acute pulmonary embolism (APE) and acute non-ST elevation myocardial infarction (NSTEMI) in order to reduce the rate of clinical misdiagnosis.

METHODS

The clinical data of 37 patients with APE and 103 patients with NSTEMI admitted to our hospital were retrospectively analyzed. The differences in the clinical manifestations, ECGs, myocardial zymograms, D-dimers, and troponin (cTn) of the two groups were compared.

RESULTS

In the patients with APE, the main symptom-found in 25 cases (67.56%)-was dyspnea, while in the patients with NSTEMI, the main symptom-found in 52 cases (50.49%)-was chest tightness. The incidences of sinus tachycardia and S_I Q_III T_III in the group of patients with APE were higher than in the group of patients with NSTEMI, and the difference was statistically significant (p < .05). There was no statistical significance in the difference of aspartate aminotransferase and lactate dehydrogenase (LDH) in the two groups (p > .05), although there was a statistically significant difference of creatine kinase (CK) and the creatine kinase isoenzyme-MB (CK-MB) in the two groups (p < .05). The levels of D-dimers and cTn were increased in both groups, but the level of D-dimers in the group of patients with APE was higher than that in the group of patients with NSTEMI.

CONCLUSION

With the occurrence of clinical manifestations like dyspnea, chest tightness, chest pain, and palpitation of unknown causes, the possibility of APE and NSTEMI should be considered.

A potential diagnostic pitfall in ST elevation: Acute pulmonary embolism or ST-segment elevation myocardial infarction

The diagnosis of acute pulmonary embolism (APE) is a great challenge for physicians due to its nonspecific symptoms, and often missed or misdiagnosed as acute coronary syndrome. Electrocardiographic (ECG) abnormalities are seen in majority of patients with APE. Recently, APE with ST‐segment elevation (STE) in leads V₁–V₃/V₄, mimicking ST‐segment elevation myocardial infarction (STEMI), has been described. However, coronary angiography showed that the patient's coronary arteries were mostly normal. Herein, we describe a case of APE presenting with STE in V₁–V₄, along with severe stenosis of the left anterior descending (LAD) artery.

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.

Clinical Significance of ST Elevation in Lead aVR in Acute Pulmonary Embolism

BACKGROUND

Prognostic stratification of patients with acute pulmonary embolism (PTE) is crucial in identifying patients who would benefit from more aggressive treatment. We aimed to examine the value of ST elevation in lead aVR (STE_aVR ) in predicting hospital mortality following PTE.

MATERIALS

Two hundred patients with a diagnosis of PTE were allocated into two groups based on the presence or absence of STE_aVR . Multivariate logistic regression analysis was used to investigate the role of "STE_aVR " in relation to the other risk factors in predicting prognosis of PTE.

RESULTS

Out of 200 patients, 24 (12.0%) had STE_aVR . Patients with STE_aVR were more likely to present with hypotension and tachycardia than those who did not have this electrocardiographic finding. A total of 33.3% of patients with STE_aVR and 13.1% of those without STE_aVR died during hospitalization. STE_aVR had a low sensitivity of 25.8% but a high specificity of 90.5% for predicting hospital mortality. Odds ratio for hospital mortality was 3.32 for STE_aVR with 95% confidence interval of 1.28-8.64 (P = 0.017) in univariate analysis. In multivariate analysis shock was the strongest predictor of hospital mortality.

CONCLUSION

The presence of STE_aVR is indicative of hemodynamic instability, thereby having the ability to predict poor outcome. However, its impact on hospital mortality disappears when the presence of shock on admission is factored in the prediction model.

The electrocardiographic characteristics of an acute embolism in the pulmonary trunk and the main pulmonary arteries

OBJECTIVE

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

ST-segment elevation in V1-V4 in acute pulmonary embolism: a case presentation and review of literature

INTRODUCTION

Electrocardiographic (ECG) abnormalities are seen in 70%-80% of patients with acute pulmonary embolism (APE). Rarely, APE presents with ST-segment elevation (STE) in leads V1-V4, mimicking ST-segment elevation myocardial infarction (STEMI). Herein, we describe a case of APE presenting with STE in V1-V3, along with a comprehensive review of the literature.

METHODS

We reviewed Pubmed/Medline indexed articles from 1950 to 2014 reporting cases of APE presenting with STE in V1-V3 or V4 (V1-V3/V4). Cases were analyzed with specific reference to patient demographics, clinical, laboratory, and radiological data, treatment, and outcome.

RESULTS

A total of 12 cases were identified comprising seven males and five females aged between 31 and 64 years. Five cases met the American College of Cardiology/American Heart Association criteria for massive APE due to sustained hemodynamic instability or requirement for inotropic support, and seven met criteria for submassive PE due to right ventricular (RV) dysfunction or elevated troponin in absence of systemic hypotension. Among the notable clinical features in this cohort is the high incidence of syncope, in 66.7% of the cases, high incidence of concomitant deep venous thrombosis (DVT) in 90% of cases that reported venous Doppler results (eight proximal and one distal DVT), and the presence of a dilated RV in 90% of the cases that reported echocardiographic results. In all but one case the initial working diagnosis was STEMI and emergent cardiac catheterization was planned. In the 90% of cases who eventually had a coronary angiography, the angiogram was performed prior to diagnosing APE, and the lack of occlusive disease prompted further workup that confirmed the diagnosis of APE. In-hospital mortality rate in the studied population was 16.7%.

CONCLUSION

STE in leads V1-V3/V4 in cases with APE identifies a subset of patients who are an intermediate to high risk category. In cases presenting with right precordial lead STE and clinical features that are more suggestive of APE rather than STEMI, a computed tomography pulmonary angiogram is warranted for earlier diagnosis of suspected APE, which allow for immediate-rather than delayed-initiation of therapeutic anticoagulant therapy if the diagnosis is confirmed and may avert the need for coronary angiography.

Use of ischemic ECG patterns for risk stratification in intermediate-risk patients with acute PE

BACKGROUND

European recommendations on the management of acute pulmonary embolism (APE) divide patients into 3 risk categories: high, intermediate, and low. Mortality has previously been estimated at 3% to 15% in the intermediate group. The aim of this study was to use a new metric "ischemic electrocardiographic (ECG) patterns" to more precisely estimate the risk (complications or death) of APE patients identified as "intermediate risk" by current European Society of Cardiology (ESC) criteria.

METHODS

The study group consisted of 500 consecutive patients (290 females), with a mean age 66.3 ± 15.2 years, and 245 (72.8%) patients were initially classified as intermediate risk. Four ischemic ECG patterns were studied: (i) ST-segment ischemic pattern (STIP), (ii) global ischemic pattern (GIP), (iii) negative T wave pattern, and (iv) control group consisting of patients with no ischemic changes.

RESULTS

Predictors of death in univariate analysis included elevated troponin concentration (odds ratio [OR], 6.8; 95% confidence interval [CI], 1.28-169; P = 0.02]) and ischemic ECG patterns: STIP (OR, 6.3; 95% CI, 1.6-46.0; P = 0.007). Patients with right ventricular dysfunction (RVD) who were STIP (+) experienced significantly higher mortality rate compared to RVD patients who were STIP(-) (11.4% vs 1.6%; OR, 7.26; 95% CI, 1.82-52.8; P = 0.004). In patients with STIP (+) as compared to STIP (-), rate of death (OR, 6.35; P = 0.007) and rate of complications (OR, 4.19; P = 0.002) were significantly higher. Neither presence of negative T-waves nor GIP pattern was associated with a worse prognosis.

CONCLUSIONS

In patients with APE, an ischemic ECG pattern on hospital admission, when identified in addition to classic risk markers, is an independent risk factor for worse in-hospital outcomes.

Electrocardiogram patterns during hemodynamic instability in patients with acute pulmonary embolism

BACKGROUND

We have previously described new electrocardiogram (ECG) findings for massive pulmonary embolism, namely ST-segment elevation in lead aVR with ST-segment depression in leads I and V4 -V6 . However, the ECG patterns of patients with acute pulmonary embolism during hemodynamic instability are not fully described.

METHODS

We compared the differences between the ECG at baseline and after deterioration during hemodynamic instability in twenty patients with acute pulmonary embolism.

RESULTS

Compared with the ECG at baseline, three ischemic ECG patterns were found during clinical deterioration with hemodynamic instability: ST-segment elevation in lead aVR with concomitant ST-segment depression in leads I and V4 -V6 , ST-segment elevation in leads V1 -V3 /V4 , and ST-segment elevation in leads III and/or V1 /V2 with concomitant ST-segment depression in leads V4 /V5 -V6 . Ischemic ECG patterns with concomitant S1Q3 and/or abnormal QRS morphology in lead V1 were more common (90%) during hemodynamic instability than at baseline (5%) (P = 0.001).

CONCLUSIONS

Hemodynamic instability in acute pulmonary embolism is reflected by signs of myocardial ischemia combined with the right ventricular strain pattern in the 12-lead ECG.