Pulmonary embolism electrocardiogram: Difference between revisions

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__NOTOC__
__NOTOC__
{| class="infobox" style="float:right;"
|-
| [[File:Siren.gif|30px|link=Pulmonary embolism resident survival guide]]|| <br> || <br>
| [[Pulmonary embolism resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']]
|}
{{Pulmonary embolism}}
{{Pulmonary embolism}}
'''Editor(s)-In-Chief:''' [[C. Michael Gibson, M.S., M.D.]] [mailto:charlesmichaelgibson@gmail.com], {{ATI}}; {{AE}} {{CZ}}
'''Editor(s)-In-Chief:''' [[C. Michael Gibson, M.S., M.D.]] [mailto:charlesmichaelgibson@gmail.com], {{ATI}}; {{AE}} {{Rim}}


==Overview==
==Overview==
EKG abnormalities in the setting of pulmonary emolism are non-specific.<ref name="pmid15863641">{{cite journal| author=Geibel A, Zehender M, Kasper W, Olschewski M, Klima C, Konstantinides SV| title=Prognostic value of the ECG on admission in patients with acute major pulmonary embolism. | journal=Eur Respir J | year= 2005 | volume= 25 | issue= 5 | pages= 843-8 | pmid=15863641 |doi=10.1183/09031936.05.00119704| pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15863641  }} </ref><ref name="pmid11018210">{{cite journal| author=Rodger M, Makropoulos D, Turek M, Quevillon J, Raymond F, Rasuli P et al.| title=Diagnostic value of the electrocardiogram in suspected pulmonary embolism. |journal=Am J Cardiol | year= 2000 | volume= 86 | issue= 7 | pages= 807-9, A10 |pmid=11018210 | doi= | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11018210  }}</ref> The EKG may also lack sensitivity as the EKG may be normal in the setting of a pulmonary embolus.  In a prospective study EKG abnormalities were present in 70% of patients with documented acute pulmonary embolism. The most common EKG abnormality was [[nonspecific ST-segment and T-wave changes]].<ref name="pmid1746481">{{cite journal| author=Stein PD, Saltzman HA, Weg JG| title=Clinical characteristics of patients with acute pulmonary embolism. | journal=Am J Cardiol | year= 1991 | volume= 68 | issue= 17 | pages= 1723-4 | pmid=1746481 | doi= |pmc= | url= }} </ref>  An electrocardiogram (ECG) is routinely performed in all patients with [[chest pain]] to assess for a [[myocardial infarction]], but the diagnosis of a [[pulmonary embolism]] should be kept in mind as well.
The [[electrocardiogram]] ([[ECG]]) in the cases of pulmonary embolism (PE) is often abnormal; however, the [[ECG]] abnormalities are neither sensitive nor specific.<ref name="pmid15863641">{{cite journal| author=Geibel A, Zehender M, Kasper W, Olschewski M, Klima C, Konstantinides SV| title=Prognostic value of the ECG on admission in patients with acute major pulmonary embolism. | journal=Eur Respir J | year= 2005 | volume= 25 | issue= 5 | pages= 843-8 | pmid=15863641 |doi=10.1183/09031936.05.00119704| pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15863641  }} </ref><ref name="pmid11018210">{{cite journal| author=Rodger M, Makropoulos D, Turek M, Quevillon J, Raymond F, Rasuli P et al.| title=Diagnostic value of the electrocardiogram in suspected pulmonary embolism. |journal=Am J Cardiol | year= 2000 | volume= 86 | issue= 7 | pages= 807-9, A10 |pmid=11018210 | doi= | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11018210  }}</ref> Some of the most common [[ECG]] abnormalities in PE include [[T wave inversion]] in the [[anterior]] leads and [[sinus tachycardia]].<ref name="pmid9118684">{{cite journal| author=Ferrari E, Imbert A, Chevalier T, Mihoubi A, Morand P, Baudouy M| title=The ECG in pulmonary embolism. Predictive value of negative T waves in precordial leads--80 case reports. | journal=Chest | year= 1997 | volume= 111 | issue= 3 | pages= 537-43 | pmid=9118684 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9118684 }} </ref><ref name="pmid123074">{{cite journal| author=Stein PD, Dalen JE, McIntyre KM, Sasahara AA, Wenger NK, Willis PW| title=The electrocardiogram in acute pulmonary embolism. | journal=Prog Cardiovasc Dis | year= 1975 | volume= 17 | issue= 4 | pages= 247-57 | pmid=123074 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=123074  }} </ref><ref name="pmid11018210">{{cite journal| author=Rodger M, Makropoulos D, Turek M, Quevillon J, Raymond F, Rasuli P et al.| title=Diagnostic value of the electrocardiogram in suspected pulmonary embolism. | journal=Am J Cardiol | year= 2000 | volume= 86 | issue= 7 | pages= 807-9, A10 | pmid=11018210 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11018210  }} </ref>  The [[ECG]] abnormalities reported in [[PE]] are also present in a variety of other conditions rendering the utility of [[ECG]] for the diagnosis of PE limited.  Nevertheless, an [[ECG]] is routinely performed in all patients with suspected PE in order to rule out other differential diagnoses such as [[myocardial infarction]].
 
== Electrocardiogram ==
== Electrocardiogram ==
=== Sinus Tachycardia ===
Various [[ECG]] abnormalities are reported in PE patients; however, the [[ECG]] findings lack [[sensitivity]] and [[specificity]] for PE.  [[T wave inversion]] in the [[anterior]] leads has been reported in many studies as the most common [[ECG]] finding among patients with PE, particularly massive PE.<ref name="pmid9118684">{{cite journal| author=Ferrari E, Imbert A, Chevalier T, Mihoubi A, Morand P, Baudouy M| title=The ECG in pulmonary embolism. Predictive value of negative T waves in precordial leads--80 case reports. | journal=Chest | year= 1997 | volume= 111 | issue= 3 | pages= 537-43 | pmid=9118684 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9118684  }} </ref><ref name="pmid123074">{{cite journal| author=Stein PD, Dalen JE, McIntyre KM, Sasahara AA, Wenger NK, Willis PW| title=The electrocardiogram in acute pulmonary embolism. | journal=Prog Cardiovasc Dis | year= 1975 | volume= 17 | issue= 4 | pages= 247-57 | pmid=123074 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=123074  }} </ref><ref name="pmid11018210">{{cite journal| author=Rodger M, Makropoulos D, Turek M, Quevillon J, Raymond F, Rasuli P et al.| title=Diagnostic value of the electrocardiogram in suspected pulmonary embolism. | journal=Am J Cardiol | year= 2000 | volume= 86 | issue= 7 | pages= 807-9, A10 | pmid=11018210 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11018210  }} </ref> In addition, the development of a Qr wave in lead V<sub>1</sub> has been reported as as an independent correlate of adverse [[prognosis]].<ref name="pmid12804925">{{cite journal |author=Kucher N, Walpoth N, Wustmann K, Noveanu M, Gertsch M |title=QR in V1--an ECG sign associated with right ventricular strain and adverse clinical outcome in pulmonary embolism |journal=[[European Heart Journal]] |volume=24 |issue=12 |pages=1113–9 |year=2003 |month=June |pmid=12804925 |doi= |url=http://eurheartj.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=12804925 |accessdate=2011-12-05}}</ref>
[[Sinus tachycardia]] is the most common ECG finding in the setting of a pulmonary embolism, but it lacks specificity.<ref name="pmid18717213">{{cite journal| author=Abecasis J, Monge J, Alberca D, Grenho MF, Arroja I, Aleixo AM| title=Electrocardiographic presentation of massive and submassive pulmonary embolism. | journal=Rev Port Cardiol | year= 2008 | volume= 27 | issue= 5 | pages= 591-610 | pmid=18717213 | doi= | pmc= | url= }} </ref>


=== T Wave Inversion ===
===Complete List of ECG Findings===
Another common ECG abnormality seen in patients with pulmonary embolism is anterior [[T-wave inversion]].<ref name="pmid9118684">{{cite journal |author=Ferrari E, Imbert A, Chevalier T, Mihoubi A, Morand P, Baudouy M |title=The ECG in pulmonary embolism. Predictive value of negative T waves in precordial leads--80 case reports |journal=[[Chest]] |volume=111 |issue=3 |pages=537–43 |year=1997 |month=March |pmid=9118684 |doi= |url=http://www.chestjournal.org/cgi/pmidlookup?view=long&pmid=9118684 |accessdate=2011-12-05}}</ref> This may represent reciprocal changes related to infero-posterior ischemia due to compression of the [[right coronary artery]] ([[RCA]]), caused by pressure overload in the [[right ventricle]] (RV).
 
Shown below is a list of [[ECG]] findings in PE:<ref name="pmid15261352">{{cite journal| author=Richman PB, Loutfi H, Lester SJ, Cambell P, Matthews J, Friese J et al.| title=Electrocardiographic findings in Emergency Department patients with pulmonary embolism. | journal=J Emerg Med | year= 2004 | volume= 27 | issue= 2 | pages= 121-6 | pmid=15261352 | doi=10.1016/j.jemermed.2004.04.007 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15261352  }} </ref><ref name="pmid9118684">{{cite journal| author=Ferrari E, Imbert A, Chevalier T, Mihoubi A, Morand P, Baudouy M| title=The ECG in pulmonary embolism. Predictive value of negative T waves in precordial leads--80 case reports. | journal=Chest | year= 1997 | volume= 111 | issue= 3 | pages= 537-43 | pmid=9118684 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9118684  }} </ref><ref name="pmid123074">{{cite journal| author=Stein PD, Dalen JE, McIntyre KM, Sasahara AA, Wenger NK, Willis PW| title=The electrocardiogram in acute pulmonary embolism. | journal=Prog Cardiovasc Dis | year= 1975 | volume= 17 | issue= 4 | pages= 247-57 | pmid=123074 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=123074  }} </ref><ref name="pmid11018210">{{cite journal| author=Rodger M, Makropoulos D, Turek M, Quevillon J, Raymond F, Rasuli P et al.| title=Diagnostic value of the electrocardiogram in suspected pulmonary embolism. | journal=Am J Cardiol | year= 2000 | volume= 86 | issue= 7 | pages= 807-9, A10 | pmid=11018210 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11018210  }} </ref>
* [[T wave inversion]] in the [[anterior]] leads (one of the most common findings, particularly in massive PE)
* [[Sinus tachycardia]] (one of the most common findings)
* [[RBBB|Incomplete RBBB]]
* [[RBBB|Complete RBBB]]
* [[S1Q3T3]]
* [[Right axis deviation]]
* [[ST segment]] and [[T wave]] non specific changes<ref name="pmid19763195">{{cite journal| author=Todd K, Simpson CS, Redfearn DP, Abdollah H, Baranchuk A| title=ECG for the diagnosis of pulmonary embolism when conventional imaging cannot be utilized: a case report and review of the literature. | journal=Indian Pacing Electrophysiol J | year= 2009 | volume= 9 | issue= 5 | pages= 268-75 | pmid=19763195 | doi= | pmc=PMC2735159 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19763195  }} </ref>
* [[P pulmonale]]<ref name="pmid19763195">{{cite journal| author=Todd K, Simpson CS, Redfearn DP, Abdollah H, Baranchuk A| title=ECG for the diagnosis of pulmonary embolism when conventional imaging cannot be utilized: a case report and review of the literature. | journal=Indian Pacing Electrophysiol J | year= 2009 | volume= 9 | issue= 5 | pages= 268-75 | pmid=19763195 | doi= | pmc=PMC2735159 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19763195  }} </ref>
* [[Low QRS voltage]]
* Normal heart rhythm
* [[ST elevation]] (rare)<ref name="pmid23449833">{{cite journal| author=Mohsen A, El-Kersh K| title=Variable ECG findings associated with pulmonary embolism. | journal=BMJ Case Rep | year= 2013 | volume= 2013 | issue=  | pages= | pmid=23449833 | doi=10.1136/bcr-2013-008697 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23449833  }} </ref>
* [[Q waves]] in the [[anterior]] leads (rare)<ref name="pmid22145193">{{cite journal |author=Raghav KP, Makkuni P, Figueredo VM |title=A review of electrocardiography in pulmonary embolism: recognizing pulmonary embolus masquerading as ST-elevation myocardial infarction |journal=Rev Cardiovasc Med |volume=12 |issue=3 |pages=157–63 |year=2011 |pmid=22145193 |doi= |url= |accessdate=2012-01-12}}</ref>


=== Right Bundle Branch Block ===
Shown below is a table summarizing the rate of occurrence of a variety of [[ECG]] findings in PE according to three different studies.
[[Right bundle branch block]] ([[RBBB]]) is commonly seen in patients with pulmonary embolism, but is neither sensitive nor specific.


=== Cor Pulmonale and Right Heart Strain ===
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
Signs of right heart strain or acute [[cor pulmonale]] may be present in patients with a large pulmonary embolism.  The classic sign of ('''S1Q3T3''') will show a large [[S wave]] in lead I, a large [[Q wave]] in lead III and an [[inverted T wave]] in lead III .<ref>McGinn S, White PD. Acute cor pulmonale resulting from pulmonary embolism. ''J Am Med Assoc'' 1935;104:1473–1480.</ref><ref name="pmid3225435">{{cite journal| author=Panos RJ, Barish RA, Whye DW, Groleau G| title=The electrocardiographic manifestations of pulmonary embolism. | journal=J Emerg Med | year= 1988 | volume= 6 | issue= 4 | pages= 301-7 | pmid=3225435 | doi= | pmc= | url= }} </ref> This can be present in up to 20% of patients, but it is also seen in other acute pulmonary conditions. It is therefore of limited diagnostic value.
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF; width: 25%" align=center | '''ECG Findings'''||style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF; width: 25%" align=center | '''Study 1'''<ref name="pmid9118684">{{cite journal| author=Ferrari E, Imbert A, Chevalier T, Mihoubi A, Morand P, Baudouy M| title=The ECG in pulmonary embolism. Predictive value of negative T waves in precordial leads--80 case reports. | journal=Chest | year= 1997 | volume= 111 | issue= 3 | pages= 537-43 | pmid=9118684 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9118684 }} </ref> ||style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF; width: 25%" align=center | '''Study 2'''<ref name="pmid123074">{{cite journal| author=Stein PD, Dalen JE, McIntyre KM, Sasahara AA, Wenger NK, Willis PW| title=The electrocardiogram in acute pulmonary embolism. | journal=Prog Cardiovasc Dis | year= 1975 | volume= 17 | issue= 4 | pages= 247-57 | pmid=123074 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=123074  }} </ref> || style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF; width: 25%" align=center |'''Study 3'''<ref name="pmid11018210">{{cite journal| author=Rodger M, Makropoulos D, Turek M, Quevillon J, Raymond F, Rasuli P et al.| title=Diagnostic value of the electrocardiogram in suspected pulmonary embolism. | journal=Am J Cardiol | year= 2000 | volume= 86 | issue= 7 | pages= 807-9, A10 | pmid=11018210 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11018210  }} </ref>
|-
| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |[[T wave inversion]] || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |68%|| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |42%|| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |44.4%
|-
| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |[[Sinus tachycardia]] ||style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |26%|| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |69% || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |42.2%
|-
| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |[[RBBB]] ||style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |22%||style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |15%|| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |4.4%-6.7%
|-
| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |[[S1Q3T3]] ||style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |50%||style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |12%|| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |11.6%
|-
| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |[[P pulmonale]] ||style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |5%||style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |6%|| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |2.2%
|-
| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |Normal [[heart rhythm]] ||style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |9%||style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |13% ||style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | -
|}


=== Q waves in the Anterior Leads with ST Elevation ===
=== T Wave Inversion ===
The presence of [[Q waves]] in the anterior leads with [[ST-elevation]] in the setting of PE has also been described in a few case reports.<ref name="pmid22145193">{{cite journal |author=Raghav KP, Makkuni P, Figueredo VM |title=A review of electrocardiography in pulmonary embolism: recognizing pulmonary embolus masquerading as ST-elevation myocardial infarction |journal=Rev Cardiovasc Med |volume=12 |issue=3 |pages=157–63 |year=2011 |pmid=22145193 |doi= |url= |accessdate=2012-01-12}}</ref>
T wave inversion in the [[anterior]] leads has been reported in many studies as the most common [[ECG]] finding among patients with PE, particularly massive PE.<ref name="pmid9118684">{{cite journal| author=Ferrari E, Imbert A, Chevalier T, Mihoubi A, Morand P, Baudouy M| title=The ECG in pulmonary embolism. Predictive value of negative T waves in precordial leads--80 case reports. | journal=Chest | year= 1997 | volume= 111 | issue= 3 | pages= 537-43 | pmid=9118684 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9118684  }} </ref><ref name="pmid123074">{{cite journal| author=Stein PD, Dalen JE, McIntyre KM, Sasahara AA, Wenger NK, Willis PW| title=The electrocardiogram in acute pulmonary embolism. | journal=Prog Cardiovasc Dis | year= 1975 | volume= 17 | issue= 4 | pages= 247-57 | pmid=123074 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=123074  }} </ref><ref name="pmid11018210">{{cite journal| author=Rodger M, Makropoulos D, Turek M, Quevillon J, Raymond F, Rasuli P et al.| title=Diagnostic value of the electrocardiogram in suspected pulmonary embolism. | journal=Am J Cardiol | year= 2000 | volume= 86 | issue= 7 | pages= 807-9, A10 | pmid=11018210 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11018210  }} </ref>  [[T wave]] inversion in the [[anterior]] leads represent reciprocal changes related to infero-posterior [[ischemia]] due to compression of the [[right coronary artery]] ([[RCA]]), caused by  pressure overload in the [[right ventricle]] following an [[acute]] PE.<ref name="pmid9654541">{{cite journal| author=Goldhaber SZ| title=Pulmonary embolism. | journal=N Engl J Med | year= 1998 | volume= 339 | issue= 2 | pages= 93-104 | pmid=9654541 | doi=10.1056/NEJM199807093390207 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9654541  }} </ref>


=== Prognostic Assessment ===
=== Cor Pulmonale and Right Heart Strain ===
ECG findings that are associated with a poor prognosis include:<ref name="pmid9118684">{{cite journal| author=Ferrari E, Imbert A, Chevalier T, Mihoubi A, Morand P, Baudouy M| title=The ECG in pulmonary embolism. Predictive value of negative T waves in precordial leads--80 case reports. | journal=Chest | year= 1997 | volume= 111 | issue= 3 | pages= 537-43 | pmid=9118684 | doi= | pmc= | url= }} </ref>
Signs of right heart [[strain]] or [[acute]] [[cor pulmonale]] may be present in patients with a massive PE.  The classic sign [[S1Q3T3]] is characterized by the presence of a large [[S wave]] in lead I, a large [[Q wave]] in lead III and an [[inverted T wave]] in lead III .<ref>McGinn S, White PD. [[Acute]][[cor pulmonale]] resulting from pulmonary embolism. ''J Am Med Assoc'' 1935;104:1473–1480.</ref><ref name="pmid3225435">{{cite journal| author=Panos RJ, Barish RA, Whye DW, Groleau G| title=The electrocardiographic manifestations of pulmonary embolism. | journal=J Emerg Med | year= 1988 | volume= 6 | issue= 4 | pages= 301-7 | pmid=3225435 | doi= | pmc= | url= }} </ref> S1Q3T3 is a sign of [[acute]] [[cor pulmonale]] that can be present in conditions other than PE.
# [[Atrial arrhythmias]]
# [[Right bundle branch block]]
# [[Q-waves]] in the inferior leads
# Precordial [[T-wave inversion]] and [[ST-segment]] changes.
# Development of a QR wave in lead V<sub>1</sub> is identified as an independent risk factor for an adverse prognosis.<ref name="pmid12804925">{{cite journal |author=Kucher N, Walpoth N, Wustmann K, Noveanu M, Gertsch M |title=QR in V1--an ECG sign associated with right ventricular strain and adverse clinical outcome in pulmonary embolism |journal=[[European Heart Journal]] |volume=24 |issue=12 |pages=1113–9 |year=2003 |month=June |pmid=12804925 |doi= |url=http://eurheartj.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=12804925 |accessdate=2011-12-05}}</ref>


==Electrocardiographic Examples==
==Electrocardiographic Examples==
Shown below is an EKG of a patient with a pulmonary embolism:
Shown below is an [[EKG]] of a patient with a pulmonary embolism:
[[Image:Pulm embolism.jpg|ECG|500px|center]]
[[Image:Pulm embolism.jpg|ECG|500px|center]]
Copyleft image obtained courtesy of ECGpedia [http://www.ecgpedia.org ecgpedia]
Copyleft image obtained courtesy of ECGpedia [http://www.ecgpedia.org ecgpedia]
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Shown below is an EKG of a patient with a pulmonary embolism:
Shown below is an [[EKG]] of a patient with a pulmonary embolism:
[[Image:pulm_embolism_ecg2.jpg|ECG of a patient with pulmonary embolism showing sinus tachycardia and right axis deviation.|500px|center]]
[[Image:pulm_embolism_ecg2.jpg|ECG of a patient with pulmonary embolism showing sinus tachycardia and right axis deviation.|500px|center]]
Copyleft image obtained courtesy of ECGpedia [http://www.ecgpedia.org ecgpedia]
Copyleft image obtained courtesy of ECGpedia [http://www.ecgpedia.org ecgpedia]
----
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Shown below is an EKG of a patient with a pulmonary embolism:
Shown below is an [[EKG]] of a patient with a pulmonary embolism:
[[Image:V18.ht22.jpg|ECG of a patient with pulmonary embolism showing S1-Q3 and signs of right frontal axis deviation.|500px|center]]
[[Image:V18.ht22.jpg|ECG of a patient with pulmonary embolism showing S1-Q3 and signs of right frontal axis deviation.|500px|center]]
Image courtesy of Dr Jose Ganseman [http://www.ganseman.com/ecgbibnl.htm#_top000 Dr Ganseman's webpage: An ultimate source of EKG]
Image courtesy of Dr Jose Ganseman [http://www.ganseman.com/ecgbibnl.htm#_top000 Dr Ganseman's webpage: An ultimate source of EKG]
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Shown below is an EKG of a patient with a pulmonary embolism:
Shown below is an [[EKG]] of a patient with a pulmonary embolism:
[[Image:picture1.jpg|ECG of patient with pulmonary embolism showing S1 Q3 T3, Right bundle branch block pattern and flipped anterior T waves.|500px|center]]
[[Image:picture1.jpg|ECG of patient with pulmonary embolism showing S1 Q3 T3, Right bundle branch block pattern and flipped anterior T waves.|500px|center]]
Image obtained courtesy of Amal Mattu, M.D.
Image obtained courtesy of Amal Mattu, M.D.
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Shown below is an EKG of a patient with a pulmonary embolism:
Shown below is an [[EKG]] of a patient with a pulmonary embolism:
[[Image:Pulmonary_embolism,_T_wave.jpg‎|A common ECG finding in pulmonary embolism is anterior T wave inversion.|500px|center]]
[[Image:Pulmonary_embolism,_T_wave.jpg‎|A common ECG finding in pulmonary embolism is anterior T wave inversion.|500px|center]]
Image obtained courtesy of Amal Mattu, M.D.
Image obtained courtesy of Amal Mattu, M.D.
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==References==
==References==
 
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{{reflist|2}}
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[[Category:Hematology]]
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[[Category:Emergency medicine]]
[[Category:Emergency medicine]]
[[Category:Intensive care medicine]]
[[Category:Intensive care medicine]]
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Latest revision as of 23:53, 29 July 2020
Resident
Survival
Guide

Pulmonary Embolism Microchapters

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Pulmonary embolism electrocardiogram On the Web

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Editor(s)-In-Chief: C. Michael Gibson, M.S., M.D. [1], The APEX Trial Investigators; Associate Editor(s)-in-Chief: Rim Halaby, M.D. [2]

Overview

The electrocardiogram (ECG) in the cases of pulmonary embolism (PE) is often abnormal; however, the ECG abnormalities are neither sensitive nor specific.[1][2] Some of the most common ECG abnormalities in PE include T wave inversion in the anterior leads and sinus tachycardia.[3][4][2] The ECG abnormalities reported in PE are also present in a variety of other conditions rendering the utility of ECG for the diagnosis of PE limited. Nevertheless, an ECG is routinely performed in all patients with suspected PE in order to rule out other differential diagnoses such as myocardial infarction.

Electrocardiogram

Various ECG abnormalities are reported in PE patients; however, the ECG findings lack sensitivity and specificity for PE. T wave inversion in the anterior leads has been reported in many studies as the most common ECG finding among patients with PE, particularly massive PE.[3][4][2] In addition, the development of a Qr wave in lead V1 has been reported as as an independent correlate of adverse prognosis.[5]

Complete List of ECG Findings

Shown below is a list of ECG findings in PE:[6][3][4][2]

Shown below is a table summarizing the rate of occurrence of a variety of ECG findings in PE according to three different studies.

ECG Findings Study 1[3] Study 2[4] Study 3[2]
T wave inversion 68% 42% 44.4%
Sinus tachycardia 26% 69% 42.2%
RBBB 22% 15% 4.4%-6.7%
S1Q3T3 50% 12% 11.6%
P pulmonale 5% 6% 2.2%
Normal heart rhythm 9% 13% -

T Wave Inversion

T wave inversion in the anterior leads has been reported in many studies as the most common ECG finding among patients with PE, particularly massive PE.[3][4][2] T wave inversion in the anterior leads represent reciprocal changes related to infero-posterior ischemia due to compression of the right coronary artery (RCA), caused by pressure overload in the right ventricle following an acute PE.[10]

Cor Pulmonale and Right Heart Strain

Signs of right heart strain or acute cor pulmonale may be present in patients with a massive PE. The classic sign S1Q3T3 is characterized by the presence of a large S wave in lead I, a large Q wave in lead III and an inverted T wave in lead III .[11][12] S1Q3T3 is a sign of acute cor pulmonale that can be present in conditions other than PE.

Electrocardiographic Examples

Shown below is an EKG of a patient with a pulmonary embolism:

ECG
ECG

Copyleft image obtained courtesy of ECGpedia ecgpedia

Shown below is an EKG of a patient with a pulmonary embolism:

ECG of a patient with pulmonary embolism showing sinus tachycardia and right axis deviation.
ECG of a patient with pulmonary embolism showing sinus tachycardia and right axis deviation.

Copyleft image obtained courtesy of ECGpedia ecgpedia

Shown below is an EKG of a patient with a pulmonary embolism:

ECG of a patient with pulmonary embolism showing S1-Q3 and signs of right frontal axis deviation.
ECG of a patient with pulmonary embolism showing S1-Q3 and signs of right frontal axis deviation.

Image courtesy of Dr Jose Ganseman Dr Ganseman's webpage: An ultimate source of EKG

Shown below is an EKG of a patient with a pulmonary embolism:

ECG of patient with pulmonary embolism showing S1 Q3 T3, Right bundle branch block pattern and flipped anterior T waves.
ECG of patient with pulmonary embolism showing S1 Q3 T3, Right bundle branch block pattern and flipped anterior T waves.

Image obtained courtesy of Amal Mattu, M.D.

Shown below is an EKG of a patient with a pulmonary embolism:

A common ECG finding in pulmonary embolism is anterior T wave inversion.
A common ECG finding in pulmonary embolism is anterior T wave inversion.

Image obtained courtesy of Amal Mattu, M.D.

References

  1. ↑ Geibel A, Zehender M, Kasper W, Olschewski M, Klima C, Konstantinides SV (2005). "Prognostic value of the ECG on admission in patients with acute major pulmonary embolism". Eur Respir J. 25 (5): 843–8. doi:10.1183/09031936.05.00119704. PMID 15863641.
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 Rodger M, Makropoulos D, Turek M, Quevillon J, Raymond F, Rasuli P; et al. (2000). "Diagnostic value of the electrocardiogram in suspected pulmonary embolism". Am J Cardiol. 86 (7): 807–9, A10. PMID 11018210.
  3. ↑ 3.0 3.1 3.2 3.3 3.4 Ferrari E, Imbert A, Chevalier T, Mihoubi A, Morand P, Baudouy M (1997). "The ECG in pulmonary embolism. Predictive value of negative T waves in precordial leads--80 case reports". Chest. 111 (3): 537–43. PMID 9118684.
  4. ↑ 4.0 4.1 4.2 4.3 4.4 Stein PD, Dalen JE, McIntyre KM, Sasahara AA, Wenger NK, Willis PW (1975). "The electrocardiogram in acute pulmonary embolism". Prog Cardiovasc Dis. 17 (4): 247–57. PMID 123074.
  5. ↑ Kucher N, Walpoth N, Wustmann K, Noveanu M, Gertsch M (2003). "QR in V1--an ECG sign associated with right ventricular strain and adverse clinical outcome in pulmonary embolism". European Heart Journal. 24 (12): 1113–9. PMID 12804925. Retrieved 2011-12-05. Unknown parameter |month= ignored (help)
  6. ↑ Richman PB, Loutfi H, Lester SJ, Cambell P, Matthews J, Friese J; et al. (2004). "Electrocardiographic findings in Emergency Department patients with pulmonary embolism". J Emerg Med. 27 (2): 121–6. doi:10.1016/j.jemermed.2004.04.007. PMID 15261352.
  7. ↑ 7.0 7.1 Todd K, Simpson CS, Redfearn DP, Abdollah H, Baranchuk A (2009). "ECG for the diagnosis of pulmonary embolism when conventional imaging cannot be utilized: a case report and review of the literature". Indian Pacing Electrophysiol J. 9 (5): 268–75. PMC 2735159. PMID 19763195.
  8. ↑ Mohsen A, El-Kersh K (2013). "Variable ECG findings associated with pulmonary embolism". BMJ Case Rep. 2013. doi:10.1136/bcr-2013-008697. PMID 23449833.
  9. ↑ Raghav KP, Makkuni P, Figueredo VM (2011). "A review of electrocardiography in pulmonary embolism: recognizing pulmonary embolus masquerading as ST-elevation myocardial infarction". Rev Cardiovasc Med. 12 (3): 157–63. PMID 22145193. |access-date= requires |url= (help)
  10. ↑ Goldhaber SZ (1998). "Pulmonary embolism". N Engl J Med. 339 (2): 93–104. doi:10.1056/NEJM199807093390207. PMID 9654541.
  11. ↑ McGinn S, White PD. Acutecor pulmonale resulting from pulmonary embolism. J Am Med Assoc 1935;104:1473–1480.
  12. ↑ Panos RJ, Barish RA, Whye DW, Groleau G (1988). "The electrocardiographic manifestations of pulmonary embolism". J Emerg Med. 6 (4): 301–7. PMID 3225435.

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