Prognostic value of the ECG on admission in patients with acute major pulmonary embolism

The Significance of Right-Sided Precordial ECG Leads (V3R and V4R) in Assessing Right Ventricular Dysfunction: A Single Center Cross-Sectional Study

BACKGROUND

Right ventricular systolic dysfunction is associated with poor prognosis and increased mortality rates. Our objective was to investigate ECG changes in patients with this condition, focusing on the right-sided precordial leads.

METHODS

In this cross-sectional study, 60 patients with right ventricular dysfunction were included from April 2020 to April 2021. Cardiac structure and function were assessed using 2D transthoracic echocardiography. Standard 12-lead electrocardiograms and right-sided precordial ECGs (V3R-V4R) were obtained and analyzed for QRS complex configuration, ST-segment elevation, and T-wave morphology.

RESULTS

In our study, the majority were male (70.0%) with a mean age of 58.76 years. The most common initial diagnoses were pulmonary thromboembolism (43.3%), chronic obstructive pulmonary disease (26.7%), and pulmonary hypertension (25.0%). The predominant ECG finding in the right-sided precordial leads (V3R, V4R) was a deep negative T wave (90.0%). Patients with severe right ventricular systolic dysfunction often exhibited a qR pattern (41.2%), whereas those with nonsevere dysfunction showed rS and QS patterns (55.8%). Approximately 41.0% of severe RV dysfunction cases had ST segment depression in the right-sided precordial leads, and 28.0% of patients displayed signs of right atrial abnormality.

CONCLUSION

The study found that qR, rS, and QS patterns were more prevalent in V3R and V4R leads among patients with severe and nonsevere right ventricular systolic dysfunction. The most common ECG feature observed was deep T-wave inversion in these leads. The study recommends using right-sided precordial leads in all patients with RV systolic dysfunction for early detection and risk stratification.

Screening for RV Dysfunction Using Smartphone ECG Analysis App: Validation Study with Acute Pulmonary Embolism Patients

Background: Acute pulmonary embolism (PE) is a critical condition where the timely and accurate assessment of right ventricular (RV) dysfunction is important for patient management. Given the limited availability of echocardiography in emergency departments (EDs), an artificial intelligence (AI) application that can identify RV dysfunction from electrocardiograms (ECGs) could improve the treatment of acute PE. Methods: This retrospective study analyzed adult acute PE patients in an ED from January 2021 to December 2023. We evaluated a smartphone application which analyzes printed ECGs to generate digital biomarkers for various conditions, including RV dysfunction (QCG-RVDys). The biomarker's performance was compared with that of cardiologists and emergency physicians. Results: Among 116 included patients, 35 (30.2%) were diagnosed with RV dysfunction. The QCG-RVDys score demonstrated significant effectiveness in identifying RV dysfunction, with a receiver operating characteristic-area under the curve (AUC) of 0.895 (95% CI, 0.829-0.960), surpassing traditional biomarkers such as Troponin I (AUC: 0.692, 95% CI: 0.536-0.847) and ProBNP (AUC: 0.655, 95% CI: 0.532-0.778). Binarized based on the Youden Index, QCG-RVDys achieved an AUC of 0.845 (95% CI: 0.778-0.911), with a sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 91.2% (95% CI: 82.4-100%), 77.8% (95% CI: 69.1-86.4%), 63.3% (95% CI: 54.4-73.9%), and 95.5% (95% CI: 90.8-100%), respectively, significantly outperforming all the expert clinicians, with their AUCs ranging from 0.628 to 0.683. Conclusions: The application demonstrates promise in rapidly assessing RV dysfunction in acute PE patients. Its high NPV could streamline patient management, potentially reducing the reliance on echocardiography in emergency settings.

Optimal hemodynamic parameters for risk stratification in acute pulmonary embolism patients

Hemodynamic assessment of patients with pulmonary embolism (PE) remains a fundamental component of early risk stratification that in turn, influences subsequent monitoring and therapeutic strategies. The current body of literature and international evidence-based clinical practice guidelines focus mainly on the use of systolic blood pressure (SBP). The accuracy of this single hemodynamic parameter, however, and its optimal values for the identification of hemodynamic instability have been recently questioned by clinicians. For example, abnormal SBP or shock index may be a late indicator of adverse outcomes, signaling a patient in whom the cascade of hemodynamic compromise is already well underway. The aim of the present article is to review the current evidence supporting the use of SBP and analyze the potential integration of other parameters to assess the hemodynamic stability, impending clinical deterioration, and guide the reperfusion treatment in patients with PE, as well as to suggest potential strategies to further investigate this issue.

Electrocardiographic Changes after Endovascular Mechanical Thrombectomy in a Patient with Pulmonary Embolism-A Case Report and Literature Review

Background: Pulmonary embolism (PE) is a common disease with an annual incidence of about 1/1000 persons. About every sixth patient dies within the first 30 days after diagnosis. The electrocardiogram (ECG) is one of the first diagnostic tests performed, and is able to confirm the suspicion of PE with typical electrocardiographic signs. Some ECG signs and their regression are also prognostically relevant. Endovascular mechanical thrombectomy is one option for PE treatment, and aims to relieve right heart strain immediately. The first studies on endovascular mechanical thrombectomy using a dedicated device (FlowTriever System, Inari Medical, Irvine, CA, USA) yielded promising results. Methods: In the following, we report the case of a 66-year-old male patient who presented with New York Heart Association III dyspnea in our emergency department. Among typical clinical and laboratory results, he displayed very impressive electrocardiographic and radiological findings at the time of PE diagnosis. Results: After endovascular mechanical thrombectomy, the patient's complaints and pulmonary hemodynamics improved remarkably. In contrast, the ECG worsened paradoxically 18 h after intervention. Nevertheless, control echocardiography 4 days after the intervention no longer showed any signs of right heart strain, and dyspnea had disappeared completely. At a 4-month follow-up visit, the patient presented as completely symptom-free with a high quality of life. His ECG and echocardiography were normal and excluded recurrent right heart strain. Conclusions: Overall, the patient benefitted remarkably from endovascular mechanical thrombectomy, resulting in an almost complete resolution of electrocardiographic PE signs at the 4-month follow-up after exhibiting multiple typical electrocardiographic PE signs at time of diagnosis and initial electrocardiographic worsening 18 h post successful intervention.

Electrocardiogram Features in Non-Cardiac Diseases: From Mechanisms to Practical Aspects

Despite the noteworthy advancements and the introduction of new technologies in diagnostic tools for cardiovascular disorders, the electrocardiogram (ECG) remains a reliable, easily accessible, and affordable tool to use. In addition to its crucial role in cardiac emergencies, ECG can be considered a very useful ancillary tool for the diagnosis of many non-cardiac diseases as well. In this narrative review, we aimed to explore the potential contributions of ECG for the diagnosis of non-cardiac diseases such as stroke, migraine, pancreatitis, Kounis syndrome, hypothermia, esophageal disorders, pulmonary embolism, pulmonary diseases, electrolyte disturbances, anemia, coronavirus disease 2019, different intoxications and pregnancy.

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.

Integrating Cardiac Biomarkers and Electrocardiogram in Pulmonary Embolism Prognosis

Pulmonary embolism (PE) represents a significant clinical challenge that substantially impacts healthcare systems. This case report focuses on the nuances of risk stratification in PE, highlighted through the presentation of a 64-year-old female patient. The uniqueness of this case lies in the patient's atypical presentation, where decreased exercise tolerance was the sole symptom leading to the diagnosis of PE. The patient was found to have new-onset atrial fibrillation, elevated levels of N-terminal pro-brain natriuretic peptide (NT-proBNP), and signs of right ventricular strain on imaging. This scenario underscores the necessity for a comprehensive assessment in PE cases, particularly when classic symptoms (e.g., tachycardia, shortness of breath, chest pain) are absent. We explore the incidence of PE in patients diagnosed with deep vein thrombosis, examining the critical role of cardiac biomarkers, including B-type natriuretic peptide, NT-proBNP, and troponins, in prognostication and their potential use in risk assessment tools for PE patients. Additionally, the significance of electrocardiogram evaluation in these patients and its role in risk stratification is thoroughly assessed.

The Zurkurnai ECG Pattern: A Novel ECG Pattern of the High-Risk Features of Acute Pulmonary Embolism

Acute pulmonary embolism is an important differential diagnosis in patients presenting with acute shortness of breath. However, the overlapping clinical presentation between acute coronary syndrome, aortic dissection, pneumonia, and heart failure made the diagnosis of pulmonary embolism very challenging in a limited resources center. We present a case of acute pulmonary embolism with an uncommon ECG pattern that was initially misdiagnosed as acute coronary syndrome. The authors made the appropriate diagnosis using the Zurkurnai ECG pattern in acute pulmonary embolism, which is defined as the presence of right axis deviation, deep symmetrical T wave inversion in V1 to V5, II, III, and AVF with the maximum at V3-V4 and poor R wave progression, which indicates the high-risk features of acute pulmonary embolism.

Electrocardiogram monitoring as a predictor of neurological and survival outcomes in patients with out-of-hospital cardiac arrest: a single-center retrospective observational study

Introduction

This study hypothesized that monitoring electrocardiogram (ECG) waveforms in patients with out-of-hospital cardiac arrest (OHCA) could have predictive value for survival or neurological outcomes. We aimed to establish a new prognostication model based on the single variable of monitoring ECG waveforms in patients with OHCA using machine learning (ML) techniques.

Methods

This observational retrospective study included successfully resuscitated patients with OHCA aged ≥ 18 years admitted to an intensive care unit in Japan between April 2010 and April 2020. Waveforms from ECG monitoring for 1 h after admission were obtained from medical records and examined. Based on the open-access PTB-XL dataset, a large publicly available 12-lead ECG waveform dataset, we built an ML-supported premodel that transformed the II-lead waveforms of the monitoring ECG into diagnostic labels. The ECG diagnostic labels of the patients in this study were analyzed for prognosis using another model supported by ML. The endpoints were favorable neurological outcomes (cerebral performance category 1 or 2) and survival to hospital discharge.

Results

In total, 590 patients with OHCA were included in this study and randomly divided into 3 groups (training set, n = 283; validation set, n = 70; and test set, n = 237). In the test set, our ML model predicted neurological and survival outcomes, with the highest areas under the receiver operating characteristic curves of 0.688 (95% CI: 0.682-0.694) and 0.684 (95% CI: 0.680-0.689), respectively.

Conclusion

Our ML predictive model showed that monitoring ECG waveforms soon after resuscitation could predict neurological and survival outcomes in patients with OHCA.

Clinical predictors of pulmonary embolism for inpatients: are computed tomography pulmonary angiograms being requested appropriately?

BACKGROUND

The heterogeneity of inpatient pulmonary embolism (PE) presentations may lead to computed tomography pulmonary angiograms (CTPA) being over-requested. Current clinical predictors for PE, including Wells criteria and Pulmonary Embolism Rule-out Criteria (PERC), have predominantly focussed on outpatient and emergency department populations.

AIM

To determine the clinical indicators for ordering inpatient CTPA and the predictors of positive scans for PE.

METHODS

Consecutive inpatient CTPA (performed >24 h after admission) from January 2017 to December 2017 were retrospectively reviewed. Variables including baseline characteristics, vital signs and risk factors for PE were extracted.

RESULTS

A total of 312 CTPA was reviewed (average patient age 67 years; 46% male) and 36 CTPA were positive for PE (11.5%). The average time to inpatient CTPA request was 7 days. Clinical indicators associated with positive scans were hypoxia (odds ratio (OR) 2.4; 95% confidence interval (CI) 1.1-5.6), tachypnoea (OR 2.5; 95% CI 1.2-6.0), recent surgery or immobilisation (OR 2.7; 95% CI 1.2-6.4), S1Q3T3 pattern on electrocardiogram (ECG; OR 7.2; 95% CI 1.4-35.7) and right bundle branch block pattern on ECG (OR 4.7; 95% CI 1.6-13.1). Hypotension, fever and malignancy were not significant. Both PERC and Wells criteria had poor positive predictive value (12% and 27% respectively), but the negative predictive value for PERC and Wells was 100% and 95.8% respectively.

CONCLUSION

Inpatient CTPA appear to be over-requested and can potentially be rationalised based on a combination of clinical predictors and Wells criteria and/or PERC rule. Further prospective studies are needed to develop accurate clinical decision tools targeted towards inpatients.

The impact of right bundle branch block and SIQIII-type patterns in determining risk levels in acute pulmonary embolism

Background: Electrocardiography (ECG) findings in acute pulmonary embolism (PE) are known to be related to various right ventricular (RV) alterations. These abnormalities are not included in risk stratification algorithms despite emerging evidence of their association with patient outcomes. We aimed to analyze the impact of right bundle branch block (RBBB) and/or SIQIII patterns as indicators for determining the level of risk in patients with PE. Methods: We performed a retrospective cohort study including all patients with confirmed acute PE hospitalized from January 2008 to December 2019 in two tertiary care cardiology departments. The first ECG taken at admission was selected and the analysis focused on the presence of a complete or an incomplete RBBB and SIQIII-type patterns. Results: A total of 255 patients were divided into two groups: Group I (47.8%, n=122) included patients with PE without RBBB nor SIQIII patterns, and Group II (52.2%, n=133) included patients with RBBB and/or SIQIII patterns. Patients in group II presented significantly more frequently with acute right heart symptoms (45.1% vs. 18%, p<0.001) and cardiogenic shock at admission (31.6 vs. 4.1%, p<0.001). Echocardiographic parameters indicating right heart injury also occurred more significantly in group II patients (p<0.001). By univariate analysis, patients in group II were found to be significantly associated with in-hospital mortality (22.6 vs. 6.1%, p=0.002) and major cardiovascular events (MACEs) during hospitalization (43.3 vs. 13.7%, p<0.001). Multivariate logistic regression analysis identified five independent factors predictive of MACEs: SIQIII and/or RBBB, renal failure, positive troponin levels, RV dysfunction and right heart failure symptoms during initial presentation. Kaplan-Meier survival analysis identified the inclusion in Group II and the presence of SIQIII pattern as predictors of overall mortality (p<0.001). Conclusions: Our study suggests an important and independent prognostic value of RBBB and SIQIII patterns and their usefulness in determining the outcome of PE patients.

New-Onset Paroxysmal Atrial Fibrillation in the Setting of Acute Pulmonary Embolism Is Associated with All-Cause Hospital Mortality in Women but Not in Men

BACKGROUND

Patients with acute pulmonary embolism (PE) may have various types of atrial fibrillation (AF). The role of AF in hemodynamic states and outcomes may differ between men and women.

METHODS

In total, 1600 patients (743 males and 857 females) with acute PE were enrolled in this study. The severity of PE was assessed using the European Society of Cardiology (ESC) mortality risk model. Patients were allocated into three groups according to their electrocardiography recordings taken during hospitalization: sinus rhythm, new-onset paroxysmal AF, and persistent/permanent AF. The association between the types of AF and all-cause hospital mortality was tested using regression models and net reclassification index (NRI) and integrated discrimination index (IDI) statistics with respect to sex.

RESULTS

There were no differences between the frequencies of the types of AF between men and women: 8.1% vs. 9.1% and 7.5% vs. 7.5% (p = 0.766) for paroxysmal and persistent/permanent AF, respectively. We found that the rates of paroxysmal AF significantly increased across the mortality risk strata in both sexes. Among the types of AF, the presence of paroxysmal AF had a predictive value for all-cause hospital mortality independent of mortality risk and age in women only (adjusted HR, 2.072; 95% CI, 1.274-3.371; p = 0.003). Adding paroxysmal AF to the ESC risk model did not improve the reclassification of patient risk for the prediction of all-cause mortality, but instead enhanced the discriminative power of the existing model in women only (NRI, not significant; IDI, 0.022 (95% CI, 0.004-0.063); p = 0.013).

CONCLUSION

The occurrence of paroxysmal AF in female patients with acute PE has predictive value for all-cause hospital mortality independent of age and mortality risk.

Coronavirus disease 2019 death prediction by electrocardiographic abnormalities and elevated D-dimer levels

Background

Electrocardiography (ECG) plays a very important role in various cardiovascular diseases and elevated D-dimer in serum associated with thrombosis. In patients with coronavirus disease 2019 (COVID-19), immense pieces of evidence showed that ECG abnormalities or elevated D-dimer in serum occurred frequently. However, it remains unclear whether ECG abnormalities combined with elevated D-dimer could be a new risk predictor in patients with COVID-19.

Methods and results

This retrospective cohort study enrolled 416 patients with COVID-19 at Wuhan Tongji Hospital from 1 February to 20 March 2020. ECG manifestations, D-dimer levels, and in-hospital deaths were recorded for all patients. Logistic regression analysis was performed to examine the association between ECG manifestations and in-hospital mortality in patients with elevated D-dimer levels. In patients hospitalized for COVID-19, ST-T abnormalities (34.3%) were the most frequent ECG manifestations, whereas sinus tachycardia (ST) (13.3%) and atrial arrhythmias with rapid rhythms (8.5%) were the two most common cardiac arrhythmias. Compared to severely ill patients with COVID-19, ST-T abnormalities, ST and atrial arrhythmias (p<0.001) with rapid rhythms, D-dimer levels, and in-hospital deaths were significantly more frequent in critically ill patients with COVID-19. Moreover, elevated D-dimer levels were observed in all the patients who died. In the subgroup of 303 patients with elevated serum D-dimer levels, the patient's age, the incidence of ST-T abnormalities, ST, atrial fibrillation (AF), and atrial premature beat were significantly higher than those in the non-elevated D-dimer subgroup. Multivariate logistic regression analysis further revealed that ST and AF were risk factors for in-hospital mortality in COVID-19 patients with elevated D-dimer levels.

Conclusions

ECG abnormalities and elevated D-dimer levels were associated with a higher risk of critical illness and death in patients hospitalized for COVID-19. ECG abnormalities, including ST and AF, combined with elevated D-dimer levels, can be used to predict death in COVID-19.

Risk stratification to optimize the management of acute pulmonary embolism

INTRODUCTION

Pulmonary embolism (PE) is a life-threatening disease. Risk stratification in patients with acute PE can guide clinical decisions. Clinical assessment, including hemodynamics, respiratory parameters, patient history, and right ventricle evaluation, has a pivotal role in this scope.

AREAS COVERED

This review aims to describe: i) the role of individual tools for prognostic stratification, from simple clinical parameters to the models suggested by international guidelines; ii) the implications of risk stratification in terms of patient disposition and treatment. The bleeding risk assessment in acute PE was also reviewed. The literature search was performed in PubMed and Embase to address these issues.

EXPERT OPINION

Prognostic assessment is essential to proceed with life-saving treatments in hemodynamically unstable patients and consider home treatment or short hospital stay in patients at low risk for death. In hemodynamically stable patients, risk stratification allows the implementation of personalized treatment pathways to reduce the risk of death, early PE recurrence, and bleeding. With the aim of optimizing healthcare resources, risk stratification may suggest appropriate patient disposition.

A Novel Electrocardiography Model for the Diagnosis of Acute Pulmonary Embolism

Acute pulmonary embolism (acPE) is a severe disease that is often misdiagnosed as it is difficult to detect quickly and accurately. In this study, a novel electrocardiogram (ECG) model was used to estimate the probability of acPE rapidly via analysis of ECG characteristics. A total of 327 patients with acPE who were diagnosed at the Sichuan Provincial People's Hospital (SPPH) between 2018 and 2021 were retrospectively studied. A total of 331 patients were randomly selected as the control group, which included patients hospitalized during the same time period. The control group included patients who presented with characteristic symptoms of acPE, but this diagnosis was ruled out following further diagnostic testing. This study compared the diagnostic value of the ECG model with those of another ECG scoring model (Daniel-ECG score) and the most common prediction models (Wells score and Geneva score). This study established an ECG-predictive model using analysis of the ECG abnormalities in patients with acPE. The final ECG model included certain novel ECG signs that had not been incorporated in the previous ECG score of the patients, and thus, compared to the previous ECG score, exhibited a more favorable area under the receiver operating characteristic curve (AUC) value (0.8741). The model developed in this study was named the SPPH-ECG model. Furthermore, this study compared the SPPH-ECG model with Daniel-ECG score, Wells score, and Geneva score, and the SPPH-ECG model was demonstrated to exhibit a superior AUC value (0.8741), sensitivity (79.08%), negative predictive value (79.52%), and test accuracy (79.42%), while the Geneva score presented superior specificity (100%) and positive predictive value (100%) compared with the SPPH-ECG model. In conclusion, the SPPH-ECG model may play a role in ruling out acPE in patients during diagnostic testing and diagnose acPE rapidly and accurately in combination with the Geneva scoring system.

Retrospective cohort study of new-onset atrial fibrillation in acute pulmonary embolism on prognosis

OBJECTIVES

To investigate the characteristics of new-onset atrial fibrillation (AF) and its impact on prognosis in acute pulmonary embolism (aPE).

DESIGN

A retrospective cohort study SETTING: The study cohort included patients diagnosed with aPE who were admitted to the Renmin Hospital of Wuhan University from January 2017 to January 2019.

PARTICIPANTS

Patients were ≥18 years of age and hospitalised for aPE.

OUTCOME MEASURES

AF was diagnosed based on an ECG recording or a Holter monitor during hospitalisation. aPE was diagnosed by CT pulmonary angiography. The prescription was determined from the discharge medication list. All-cause mortality was observed after 6-month follow-up. The logistic regression model and Cox proportional hazards model were used to study the risk factor of the new-onset AF and the predictor of all-cause mortality, respectively.

RESULTS

A total of 590 patients with aPE were enrolled, 23 (3.9%) in the new-onset paroxysmal AF group, 31 (5.3%) in the new-onset persistent AF group and 536 (90.8%) in the sinus rhythm (SR) group. The incidence of the new-onset AF was 9.2% (54/590). A significant difference in age, heart rate, cardiac troponin I ultra, amino-terminal pro-brain natriuretic peptide, D-dimer, left atrial diameter, left ventricular ejection fraction, pulmonary infection, venous thromboembolism, congestive heart failure, chronic cor pulmonale and ischaemic heart disease was found among the three groups (p<0.05). Risk factors for the new-onset AF were massive PE, ischaemic heart disease and congestive heart failure. The survival rate of the paroxysmal and persistent AF group was significantly lower than that of the SR group within 6 months (60.9% and 51.6% vs 88.8%, p<0.001). New-onset persistent AF (OR 2.73; 95% CI 1.28 to 5.81; p=0.009) was an independent predictor affecting the 6-month survival in aPE patients.

CONCLUSIONS

Massive PE, ischaemic heart disease and congestive heart failure are high-risk factors which were related to new-onset AF in aPE. New-onset persistent AF was an independent predictor for 6-month all-cause mortality in PE patients.

Sudden Death in Adults: A Practical Flow Chart for Pathologist Guidance

The medico-legal term "sudden death (SD)" refers to those deaths that are not preceded by significant symptoms. SD in apparently healthy individuals (newborn through to adults) represents a challenge for medical examiners, law enforcement officers, and society as a whole. This review aims to introduce a useful flowchart that should be applied in all cases of SD. Particularly, this flowchart mixes the data obtained through an up-to-date literature review and a revision of the latest version of guidelines for autopsy investigation of sudden cardiac death (SCD) in order to support medico-legal investigation. In light of this review, following the suggested flowchart step-by-step, the forensic pathologist will be able to apply all the indications of the scientific community to real cases. Moreover, it will be possible to answer all questions relative to SD, such as: death may be attributable to cardiac disease or to other causes, the nature of the cardiac disease (defining whether the mechanism was arrhythmic or mechanical), whether the condition causing SD may be inherited (with subsequent genetic counseling), the assumption of toxic or illicit drugs, traumas, and other unnatural causes.

[Cardiac arrest under special circumstances]

These guidelines of the European Resuscitation Council (ERC) Cardiac Arrest under Special Circumstances are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the modifications required for basic and advanced life support for the prevention and treatment of cardiac arrest under special circumstances; in particular, specific causes (hypoxia, trauma, anaphylaxis, sepsis, hypo-/hyperkalaemia and other electrolyte disorders, hypothermia, avalanche, hyperthermia and malignant hyperthermia, pulmonary embolism, coronary thrombosis, cardiac tamponade, tension pneumothorax, toxic agents), specific settings (operating room, cardiac surgery, cardiac catheterization laboratory, dialysis unit, dental clinics, transportation [in-flight, cruise ships], sport, drowning, mass casualty incidents), and specific patient groups (asthma and chronic obstructive pulmonary disease, neurological disease, morbid obesity, pregnancy).

European Resuscitation Council Guidelines 2021: Cardiac arrest in special circumstances

These European Resuscitation Council (ERC) Cardiac Arrest in Special Circumstances guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the modifications required to basic and advanced life support for the prevention and treatment of cardiac arrest in special circumstances; specifically special causes (hypoxia, trauma, anaphylaxis, sepsis, hypo/hyperkalaemia and other electrolyte disorders, hypothermia, avalanche, hyperthermia and malignant hyperthermia, pulmonary embolism, coronary thrombosis, cardiac tamponade, tension pneumothorax, toxic agents), special settings (operating room, cardiac surgery, catheter laboratory, dialysis unit, dental clinics, transportation (in-flight, cruise ships), sport, drowning, mass casualty incidents), and special patient groups (asthma and COPD, neurological disease, obesity, pregnancy).

Prediction of Mortality Associated with Cardiac and Radiological Findings in Patients with Pulmonary Embolism

Background: In this study, we aimed to compare echocardiography, electrocardiography (ECG) abnormalities, Doppler ultrasonography (USG), and computed tomography pulmonary angiography (CTPA) results in predicting 3-month mortality in patients with acute pulmonary embolism (PE).

Methods: This retrospective cohort study included 124 patients (72 females, 52 males) with acute PE. Demographics, symptoms, clinical signs, comorbidities, history of surgery, arterial blood gas, liver-renal functions, complete blood count, echocardiography, ECG, Doppler USG, and CTPA results, as well as 3-month mortality were recorded.

Results: pH (z = –2.623; p <0.01), hemoglobin (z = –3.112; p <0.01), and oxygen saturation (z = –2.165; p <0. 01) were significantly higher in survivors. White blood cell (z = –2.703; p <0.01), blood urea nitrogen (z = –3.840; p <0.01), creatinine (z = –3.200; p <0.01), respiratory rate (z = –2.759; p <0.01), and heart rate (z = –2.313; p <0.01) were significantly higher in non-survivors. Nonspecific ST changes (AUC 0.52, 95% CI 0.43–0.61), p pulmonale (AUC 0.52, 95% CI 0.43–0.61), normal axis (AUC 0.61), right axis deviation (AUC 0.56), right ventricle strain pattern (AUC 0.59), and right pulmonary artery embolism (AUC 0.54) on CTPA showed the highest mortality prediction.

Conclusions: Nonspecific ST changes, p pulmonale, normal axis and right axis deviation in ECG, RV strain in echocardiography, and right pulmonary artery embolism on CTPA are associated with a higher mortality in patients with PE.

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 Prognostic Value of Syncope on Mortality in Patients With Pulmonary Embolism: A Systematic Review and Meta-analysis

STUDY OBJECTIVE

Syncope is a presenting symptom in 10% to 20% of patients with pulmonary embolism. We perform a meta-analysis to clarify the prognostic value of syncope on short-term mortality in pulmonary embolism patients and its association with hemodynamic instability.

METHODS

PubMed, EMBASE, and the Cochrane Library were searched up until January 7, 2020. Studies reporting inhospital or 30-day mortality of adults with pulmonary embolism with and without syncope were included. Quality of included studies was evaluated with the Quality in Prognosis Studies tool. Meta-analysis was conducted to derive pooled odds ratios (ORs) and risk differences for the relation of syncope with mortality and hemodynamic instability. To study the influence of hemodynamic instability on the association between syncope and mortality, meta-regression was performed.

RESULTS

Search and selection resulted in 26 studies, of which 20 were pooled, involving 9,419 of 335,120 patients (3%) with syncope. Syncope was associated with higher mortality (OR 1.82; 95% confidence interval [CI] 1.14 to 2.90; I2 88%; risk difference 4% [95% CI 1% to 8%]) and higher prevalence of hemodynamic instability (OR 4.36; 95% CI 2.27 to 8.37; I2 93%; risk difference 12% [95% CI 7% to 18%]). OR for mortality in patients with pulmonary embolism with syncope versus without it was higher in the presence of a larger difference in hemodynamic instability between groups (coefficient 0.05; 95% CI 0.01 to 0.09).

CONCLUSION

The association between syncope and short-term mortality in patients with pulmonary embolism is explained by a difference in hemodynamic instability. This emphasizes the importance of risk stratification by hemodynamic status in pulmonary embolism patients with and without syncope.

Pulmonary embolism in COVID-19: Clinical characteristics and cardiac implications

BACKGROUND

The thrombogenic potential of Covid-19 is increasingly recognised. We aim to assess the characteristics of COVID-19 patients diagnosed with pulmonary embolism (PE).

METHODS

We conducted a single centre, retrospective observational cohort study of COVID-19 patients admitted between 1st March and 30th April 2020 subsequently diagnosed with PE following computed tomography pulmonary angiogram (CTPA). Patient demographics, comorbidities, presenting complaints and inpatient investigations were recorded.

RESULTS

We identified 15 COVID-19 patients diagnosed with PE (median age = 58 years [IQR = 23], 87% male). 2 died (13%), both male patients >70 years. Most common symptoms were dyspnoea (N = 10, 67%) and fever (N = 7, 47%). 12 (80%) reported 7 days or more of non-resolving symptoms prior to admission. 7 (47%) required continuous positive airway pressure (CPAP), 2 (13%) of which were subsequently intubated. All patients had significantly raised D-dimer levels, lactate dehydrogenase (LDH), C-reactive protein (CRP), ferritin and prothrombin times. The distribution of PEs correlated with the pattern of consolidation observed on CTPA in 9 (60%) patients; the majority being peripheral or subsegmental (N = 14, 93%) and only 1 central PE. 10 (67%) had an abnormal resting electrocardiogram (ECG), the commonest finding being sinus tachycardia. 6 (40%) who underwent transthoracic echocardiography (TTE) had structurally and functionally normal right hearts.

CONCLUSION

Our study suggests that patients who demonstrate acute deterioration, a protracted course of illness with non-resolving symptoms, worsening dyspnoea, persistent oxygen requirements or significantly raised D-dimer levels should be investigated for PE, particularly in the context of COVID-19 infection. TTE and to a lesser degree the ECG are unreliable predictors of PE within this context.

Association of the positive T wave in lead aVR with short-term mortality in patients with acute pulmonary embolism

Background: Lead aVR provides prognostic information in various settings for patients with cardiovascular diseases. The present study aimed to investigate the prognostic value of a positive T wave in lead aVR (TaVR) for patients with acute pulmonary embolism (APE).Methods: We screened a total of 412 consecutive patients who were hospitalised with a diagnosis of APE between 2008 and 2018. We investigated electrocardiograms (ECGs) for the presence of a positive TaVR and classified other abnormal ECG findings. Additionally, clinical data, such as echocardiographic findings were recorded, and pulmonary embolism severity index (PESI) scores were calculated. The predictors of mortality at 30 days were investigated as the clinical outcome by logistic regression analysis.Results: In our study population, 54 patients (13.1%) died within 30 days. The prevalence of female gender, congestive heart failure, chronic obstructive pulmonary disease, and mean PESI scores were significantly higher in patients with a positive TaVR compared to those without it. Systolic blood pressure of patients with positive TaVR was significantly lower than that of patients without positive TaVR. In multivariate regression analysis; PESI scores (OR: 1.03; 95% CI: 1.01-1.04, p < .01), Right ventricular end-diastolic diameter (RVEDD) (OR: 1.07 95% CI: 1.01-1.13, p = .02), and a positive TaVR (OR: 4.41; 95% CI: 1.63-11.96, p < .01) were independently correlated with mortality.Conclusion: Positive TaVR, PESI scores, and RVEDD at hospital admission may have prognostic value in patients with APE. Positive T wave in lead aVR could be a useful marker in early risk stratification of pulmonary embolism.

Acute pulmonary embolism multimodality imaging prior to endovascular therapy

The manuscript discusses the application of CT pulmonary angiography, ventilation–perfusion scan, and magnetic resonance angiography to detect acute pulmonary embolism and to plan endovascular therapy. CT pulmonary angiography offers high accuracy, speed of acquisition, and widespread availability when applied to acute pulmonary embolism detection. This imaging modality also aids the planning of endovascular therapy by visualizing the number and distribution of emboli, determining ideal intra-procedural catheter position for treatment, and signs of right heart strain. Ventilation–perfusion scan and magnetic resonance angiography with and without contrast enhancement can also aid in the detection and pre-procedural planning of endovascular therapy in patients who are not candidates for CT pulmonary angiography.

The predictive value of RS time for short term mortality in patients with acute pulmonary embolism

OBJECTIVE

Many studies have examined the capability of electrocardiography (ECG) changes to predict the severity and prognosis of patients with acute pulmonary embolism (APE). RS time in ECG is potentially valuable in evaluating the prognosis of APE. In our study, we aimed to assess the predictive value of RS time, which is a novel electrocardiographic parameter of one-month mortality of APE.

METHODS

This retrospective study included 216 patients who were diagnosed with APE by pulmonary computed tomography angiography. RS time was measured from the ECG (inferolateral leads) at the time of hospital admission using a computer program (imagej.nih.gov/ij/). The patients were divided into two groups according to the median values of RS time: the group with RS time ≤ 60 msec (n:108) and the group with RS time > 60 msec (n:108). The groups were compared in terms of mortality.

RESULTS

In our study, the one-month mortality was 15.3% (33) in the patients hospitalized with APE. In the multivariate analysis, RS time prolongation (HR: 1.037; 95%CI: 1.005-1.065; p = .02) was independently correlated with mortality. The ROC curve analysis revealed that RS time > 64.8 msec predicted the one-month mortality in APE with a sensitivity of 68.6% and a specificity of 73.9% (AUC: 0.708; 95% CI: 0.643-0.768; p < .001).

CONCLUSION

As a novel ECG parameter, RS time could be measured for each patient with APE. Prolongation of RS time could be a useful index for predicting the one-month mortality of patients diagnosed with APE.

Atrial fibrillation, venous thromboembolism, ischemic stroke, and all-cause mortality: The Tromsø study

Background

Atrial fibrillation (AF) is associated with increased risk of ischemic stroke and all-cause mortality. Patients with AF are also at increased risk of venous thromboembolism (VTE), but information on how AF impacts VTE-related mortality is scarce.

Objectives

To investigate the impact of AF on all-cause mortality in subjects with and without a thromboembolic event (VTE or ischemic stroke).

Methods

We followed 29 833 participants from the Tromsø study (1994-2008) through 2013 and recorded all deaths during follow-up. Incident AF, VTE, and ischemic stroke were registered as time-dependent exposures. We calculated mortality rates (MRs) by exposure during follow-up and obtained hazard ratios (HRs) for death with 95% confidence intervals (CIs).

Results

A total of 2087 AF cases, 756 VTEs, and 1279 ischemic strokes were registered during a median follow-up of 18.7 years, and 4797 people (16.1%) died. The age-adjusted MR for participants without any event was 1.19 per 100 person-years (PY; 95% CI, 1.15-1.23). Compared to these participants, subjects with the joint AF + VTE exposure had a 3.7-fold increased risk of death (HR, 3.67; 95% CI, 2.77-4.66) in age- and sex-adjusted analyses, similar to the risk observed for VTE alone (HR, 3.76; 95% CI, 3.28-4.30). Participants with stroke had a 2.9-fold increased risk of death (HR, 2.85; 95% CI, 2.56-3.18), and the risk was further increased in participants with both AF and stroke (HR, 4.38; 95% CI, 3.85-4.98).

Conclusions

AF was significantly associated with increased risk of death in participants with incident stroke. In contrast, concomitant AF was not associated with excess mortality risk in VTE patients.

COVID-19 Presenting as Acute Bilateral Submassive Pulmonary Embolism in a Young Healthy Female

Similar symptoms, signs, and laboratory abnormalities between coronavirus disease 2019 (COVID-19) and pulmonary embolism (PE) creates a diagnostic challenge to every physician, and emerging data show an association between COVID-19, hypercoagulable state, and venous thromboembolism. We present a rare case of COVID-19 presented as bilateral sub-massive PE. A 28-year-old COVID-19 positive female with no significant past medical history presented with a dry cough and shortness of breath for three days. Initial laboratory test showed elevated D-dimer, electrocardiogram (EKG) showed right axis deviation, right ventricular strain pattern, and SI QIII TIII pattern, and echocardiogram (ECHO) showed right ventricular dysfunction. Those two bedside tests directed the urgency of chest CT angiography that showed bilateral sub-massive PE. Since EKG finding of SI QIII TIII pattern and right ventricular strain, and ECHO finding of right ventricular dysfunction are well described in PE but not in COVID-19, these bedside diagnostic tools can help identify COVID-19 patients with underlining PEs.

Atrial fibrillation is frequent but does not affect risk stratification in pulmonary embolism

BACKGROUND

Although prior studies indicate a high prevalence of atrial fibrillation (AF) in patients with pulmonary embolism (PE), the exact prevalence and prognostic impact are unknown.

METHODS

We aimed to investigate the prevalence, risk factors and prognostic impact of AF on risk stratification, in-hospital adverse outcomes and mortality in 528 consecutive PE patients enrolled in a single-centre registry between 09/2008 and 09/2017.

RESULTS

Overall, 52 patients (9.8%) had known AF and 57 (10.8%) presented with AF on admission; of those, 34 (59.6%) were newly diagnosed with AF. Compared to patients with no AF, overt hyperthyroidism was associated with newly diagnosed AF (OR 7.89 [2.99-20.86]), whilst cardiovascular risk comorbidities were more frequently observed in patients with known AF. Patients with AF on admission had more comorbidities, presented more frequently with tachycardia and elevated cardiac biomarkers and were hence stratified to higher risk classes. However, AF on admission had no impact on in-hospital adverse outcome (8.3%) and in-hospital mortality (4.5%). In multivariate logistic regression analyses corrected for AF on admission, NT-proBNP and troponin elevation as well as higher risk classes in risk assessment models remained independent predictors of an in-hospital adverse outcome.

CONCLUSION

Atrial fibrillation is a frequent finding in PE, affecting more than 10% of patients. However, AF was not associated with a higher risk of in-hospital adverse outcomes and did not affect the prognostic performance of risk assessment strategies. Thus, our data support the use of risk stratification tools for patients with acute PE irrespective of the heart rhythm on admission.

Prognostic Value of Electrocardiography in Elderly Patients with Acute Pulmonary Embolism

BACKGROUND

Electrocardiographic (ECG) signs of right ventricular strain could be used as a simple tool to risk-stratify patients with acute pulmonary embolism.

METHODS

We studied consecutive patients aged ≥65 years with acute pulmonary embolism in a prospective multicenter cohort study. Two readers independently analyzed 12 predefined ECG signs of right ventricular strain in all patients. The outcome was the occurrence of an adverse clinical event, defined as death from any cause within 90 days or a complicated in-hospital course. We determined the interrater reliability for each ECG sign and examined the association between right ventricular strain signs and adverse events using logistic regression, adjusting for the Pulmonary Embolism Severity Index and cardiac troponin.

RESULTS

Overall, 320/390 patients (82%) showed at least one ECG sign of right ventricular strain. The interrater reliability for individual ECG signs was highly variable (ᴋ 0.40-0.95). Patients with ≥1 of the 3 classic signs of right ventricular strain (S1Q3T3, right bundle branch block, or T wave inversions in V1-V4) had a higher incidence of adverse events than those without (13% vs 6%; P = .026). After adjustment, the presence of ≥1 of the 3 classic signs of right ventricular strain (odds ratio 2.11; 95% confidence interval, 1.00-4.46) and the number of right ventricular strain signs present were significantly associated with adverse events (odds ratio 1.35 per sign; 95% confidence interval, 1.08-1.69).

CONCLUSIONS

ECG signs of right ventricular strain are common in elderly patients with acute pulmonary embolism. Although such signs may have prognostic value, their variable reliability and the rather modest prognostic effect size may limit their usefulness in the risk stratification of pulmonary embolism.

Atrial Fibrillation in Patients with Acute Pulmonary Embolism: Clinical Significance and Impact on Prognosis

Pulmonary embolism (PE) is one of the most common causes of cardiovascular death. The most often PE etiology is a deep vein thrombosis (DVT) of the lower extremities, but embolic material can arise in pelvic or upper extremity veins as well as in right heart chambers. There is growing number of evidences of atrial fibrillation (AF) involvement in PE. The presence of AF in patients with PE may be both the cause and the consequence of PE. The PE association with AF should be considered in patients without confirmed DVT and with history of AF, which itself is associated with prothrombotic state. The valuable diagnostic method is echocardiography that may bring the insight into source of embolic material. Another possible AF and PE association is the AF as a consequence of an abrupt increase in pulmonary vascular resistance due to the occlusion of the pulmonary vessels. Large-scale population-based studies have provided a considerable body of evidence on the involvement of PE in the onset of subsequent AF. Another important issue is the influence of AF on prognosis in patients with PE. Most investigators demonstrated a negative impact of AF on mortality. The main problem to resolve is whether AF is an independent mortality risk factor or whether it occurs as a result of comorbidities or the severity of a PE episode. Although the pathophysiological basis of this bidirectional relationship exists, many questions are still unresolved and require further studies, including the significance of paroxysmal AF accompanying an acute PE episode, the usefulness of PE risk scales in patients with concomitant AF, and the effect of anticoagulant treatment on PE and AF occurrence. Regardless of the type of AF, clinicians should be alert to the possibility of PE in patients with previous history of AF or presenting with new-onset AF.

Prognostic Value of ECG in Patients with Pulmonary Embolism

Aim. To study the significance of electrocardiography (ECG) signs for determining the hospital prognosis in patients with pulmonary embolism (PE).

Material and methods. 472 consecutive patients (49.6% men; average age 58.06±14.28 years) with PE, hospitalized to our center from 23.04.2003 to 18.09.2014 were enrolled into the study. In all cases PE was confirmed by computed tomographic pulmonary angiography and rarely by pulmonary angiography, or by pathology. Patients management was in accordance with appropriate European guidelines. Data of patients' history, clinical symptoms, biochemical markers and instrumental methods (ECG, echocardiography) were analyzed by one-dimensional logistic regression. The end points were: death, shock and hypotension, right ventricular dysfunction and pulmonary hypertension, positive cardiac biomarkers.

pulmonary embolism, electrocardiography, prognosis, collapse, hypotension, dysfunction of the right ventricle. 443 patients (93.9%) without fatal outcome were the first group and 29 patients (6.1%) with a fatal outcome – the second group. SIQIII pattern (33 vs 55.2%; p=0.015), non-complete right bundle branch block (RBBB) (16.3 vs 37.9%; p=0.001), ST segment elevation in lead III (9.7 vs 20.7%, p=0.034), atrial fibrillation (12.9 vs 37.9%, p=0.048) were observed more frequently among patients of group 2. Multivariate analysis revealed that SIQIII pattern (odds ratio [OR] 2.26; 95% confidence interval [95%CI] 1.046-4.868; p=0.038) and RBBB (OR 2.84; 95%CI 1.272-6.327; p=0.011) were associated with worse prognosis. The SIQIII pattern was significantly associated with a fatal outcome with a sensitivity of 55% and a specificity of 33% (AUC=0.611) according to ROC-analysis. Risk of hypotension was related to the following ECG-signs: the p-pulmonale (OR 1.76; 95%CI 1.001-3.088; p=0.049), negative T-wave in lead III (OR 1.8; 95%CI 1.035-3.144; p=0.037). Inversion of the T wave in lead III was associated with the development of shock (OR 1.98; 95%CI 0.891-4.430; p=0.043).

ECG-signs were also associated with the development of right ventricular dysfunction and pulmonary hypertension: right axis deviation (OR 1.035; 95%CI 1.008-1.062; p=0.01), ST-segment elevation in the AVR lead (OR 3.769; 95%CI 1.018-13.955; p=0.047), negative T wave in leads III, V1-V3 (OR 1.015; 95%CI 1.008-1.023; p=0.001 and OR 1.014; 95%CI 1.005-1.022; p=0.001, respectively), RBBB (OR 1.013; 95%CI 1.003- 1.024; p=0.012), p-pulmonale (OR 1.015; 95%CI 1.007-1.023; p=0.001), deep S in leads V5-V6 (OR 1.015; 95%CI 1.006-1.024; p=0.001). However, there was no significant relationship between ECG signs and cardiac biomarkers (troponin I and BNP).

Conclusions. SIQIII pattern, RBBB and inversion of the T wave in lead III have prognostic value in unselected population of patients with PE. 

ECG in suspected pulmonary embolism

Objective

To establish the diagnostic value of prespecified ECG changes in suspected pulmonary embolism (PE).

Methods

Retrospective case–control study in a district general hospital setting. We identified 189 consecutive patients with suspected PE whose CT pulmonary angiogram (CTPA) was positive for a first PE and for whom an ECG taken at the time of presentation was available. We matched these for age±3 years with 189 controls with suspected PE whose CTPA was negative. We considered those with large (n=76) and small (n=113) clot load separately. We scored each ECG for the presence or absence of eight features that have been reported to occur more commonly in PE.

Results

20%–25% of patients with PE, including those with large clot load, had normal ECGs. The most common ECG abnormality in patients with PE was sinus tachycardia (28%). S1Q3T3 (3.7%), P pulmonale (0.5%) and right axis deviation (4.2%) were infrequent findings. Right bundle branch block (9.0%), atrial dysrhythmias (10.1%) and clockwise rotation (20.1%) occurred more frequently but were also common in controls. Right ventricular (RV) strain pattern was significantly more commonly in patients than controls, 11.1% vs 2.6% (sensitivity 11.1%, specificity 97.4%; OR 4.58, 95% CI 1.63 to 15.91; p=0.002), particularly in those with large clot load, 17.1% vs 2.6% (sensitivity 17.1%, specificity 97.4%; OR 7.55, 95% CI 1.62 to 71.58; p=0.005).

Conclusion

An ECG showing RV strain in a breathless patient is highly suggestive of PE. Many of the other ECG changes that have been described in PE occur too infrequently to be of predictive value.

Characteristics of synthesized right-sided chest electrocardiograms in patients with acute pulmonary embolism

BACKGROUND

The significance of right-sided chest lead electrocardiogram (ECG) abnormalities in acute pulmonary embolism (APE) is unclear. This study evaluated the characteristics of such abnormalities in APE patients.

METHODS

This retrospective study included consecutive patients who were diagnosed with APE by contrast-enhanced computed tomography or pulmonary artery angiography. A standard 12-lead ECG and a synthesized right-sided chest ECG were obtained from these patients. Waveform differences were noted between the acute and post-treatment phases.

RESULTS

In total, 56 APE patients (18 men and 38 women, mean age 66.7±13.3 years) were included. Traditional ECG findings, such as right-axis deviation, the S₁Q₃T₃ pattern, and clockwise rotation, were found in relatively few patients (14.3%, 32.1%, and 21.4%, respectively). In some cases, a negative T wave in standard 12-lead ECGs was observed in leads III, V1, and V2 (46.4%, 60.7%, and 39.9%, respectively). Syn-V3R ECG showed a higher frequency of negative T waves (66.1%) at the onset and significantly (p<0.01) decreased at the follow-up. Multiple logistic regression analyses for differentiating APE revealed that the negative T waves only in lead syn-V3R were significantly related (odds ratio: 6.95, 95% confidence interval: 2.50-19.32, p<0.001).

CONCLUSIONS

The presence of a negative T wave in a synthesized right-sided chest ECG, particularly in the V3R lead, is a new and distinctive finding denoting pulmonary embolism. To confirm the utility of this characteristic using synthesized right-sided chest ECGs for the diagnosis of APE, further studies with larger populations will be required.

Validation of the Predictive Model of the European Society of Cardiology for Early Mortality in Acute Pulmonary Embolism

Background  Acute pulmonary embolism (PE) is burdened by high mortality, especially within 30 days from the diagnosis. The development and the validation of predictive models for the risk of early mortality allow to differentiate patients who can undergo home treatment from those who need admission into intensive care units. Methods  To validate the prognostic model for early mortality after PE diagnosis proposed by the European Society of Cardiology (ESC) in 2014, we analyzed data of a cohort of 272 consecutive patients with acute PE, observed in our hospital during a 10-year period. Moreover, we evaluated the additional contribution of D-dimer, measured at PE diagnosis, in improving the prognostic ability of the model. All cases of PE were objectively diagnosed by angiography chest CT scan or perfusion lung scan. Results  The overall mortality rate within 30 days from PE diagnosis was 10% (95% confidence interval [CI]: 6.4-13.5%). According to the ESC prognostic model, the risk of death increased 3.23 times in the intermediate-low-risk category, 5.55 times in the intermediate-high-risk category, and 23.78 times in the high-risk category, as compared with the low-risk category. The receiver operating characteristic analysis showed a good discriminatory power of the model (area under the curve [AUC] = 0.77 [95% CI: 0.67-0.87]), which further increased when D-dimer was added (AUC = 0.85 [95% CI: 0.73-0.96]). Conclusion  This study represents a good validation of the ESC predictive model whose performance can be further improved by adding D-dimer plasma levels measured at PE diagnosis.

Acute Pulmonary Embolism: Focus on the Clinical Picture

Acute pulmonary embolism (APE) is characterized by numerous clinical manifestations which are the result of a complex interplay between different organs; the symptoms are therefore various and part of a complex clinical picture. For this reason, it may not be easy to make an immediate diagnosis. This is a comprehensive review of the literature on all the various clinical pictures in order to help physicians to promptly recognize this clinical condition, remembering that our leading role as cardiologists depends on and is influenced by our knowledge and working methods.

The Role of Electrocardiography in Follow up of Pulmonary Thromboembolism

Objective

Electrocardiography (ECG) is a simple, valuable and easily applicable test that can be used in supporting the diagnosis and assessing the severity of pulmonary thromboembolism (PTE). In this study, it was aimed to identify the role of ECG scoring in diagnosis and follow up of PTE in comparison with community acquired pneumonia (CAP).

Methods

Patients with the diagnosis of PTE and CAP were included in the study prospectively between January 2007 and January 2009. ECG scorings were evaluated by two different cardiologists by the method described by Daniel et al at admission (day 0) and day 3, 10 and one month of treatment. Median values of ECG scorings were compared between days and between groups.

Results

Forty-five patients with PTE, 35 patients with CAP were included in the study. Although no statistically significant difference was identified between the ECG scorings of the two groups in each measurement point, ECG scores decreased more rapidly in PTE group within days. Within the PTE group, day 0 ECG score was identified higher in submassive patients than nonmassive ones (p=0.001).

Conclusions

Although ECG score did not differentiate PTE from CAP, depending on its rapid decrease in PTE, it can be used in the follow up. For submassive PTE patients that must be diagnosed and treated immediately, ECG scorings can be used to support the diagnosis and to assess the clinical severity.

Diagnostic value of the corrected QT difference between leads V1 and V6 in patients with acute pulmonary thromboembolism

In acute pulmonary thromboembolism (PTE), right ventricular pressure overload impairs right-sided cardiac conduction and repolarization. We hypothesized that if heterogeneity of repolarization between right and left ventricles occurs in acute PTE, there would be the difference of repolarization between them. Therefore, we aimed to evaluate the diagnostic value of corrected QT interval (QTc) difference between leads V1 and V6 (V1 - V6) in patients with acute PTE.A total of 89 patients with suspected acute PTE who underwent computed tomographic angiography (CTA) were enrolled from January to December 2015. PTE was identified by CTA. We compared electrocardiographic (ECG) parameters, especially QTc difference (V1 - V6) between patients with PTE and those without PTE.Acute PTE was finally diagnosed in 45 patients. Clinical situations including the chief complaint were not different between PTE and non-PTE groups. S1Q3T3, a traditional ECG marker, had no diagnostic value for acute PTE. Patients with PTE had a significantly longer mean QTc in V1 (454.6 ± 44.3 vs 417.5 ± 31.3 ms, P < .001) and larger QTc difference (V1 - V6) (34.8 ± 30.5 vs -12.5 ± 16.6 ms, P < .001) than non-PTE controls. QTc difference (V1 - V6) was negative in all patients without PTE. PTE patients had a higher prevalence of T wave inversion in leads III (51.1% vs 29.5%, P = .038) and V1 (82.2% vs 38.6%, P < .001). A QTc difference (V1 - V6) of ≥20 ms identified PTE with 82.2% sensitivity, 100.0% specificity, and 100.0% positive predictive value.QTc difference (V1 - V6) had an excellent diagnostic value for differentiating patients with and without acute PTE.

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.

Electrocardiographic findings in pulmonary embolism

Pulmonary embolism (PE) poses a challenge to physicians, as it can be difficult to diagnose but results in significant mortality and morbidity in patients. Diagnosing PE requires an integrated approach using clinical findings, electrocardiography (ECG), blood investigations and imaging modalities. Abnormalities in ECG are common among patients with massive acute PE and can serve as a prognostic indicator. In this article, we describe the ECG presentations of two patients diagnosed with PE, and review the literature on the various types of ECG presentations and their role in predicting the prognosis of PE.

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.