EKG Rounds Mark Bromley PGY3

Objectives  Identify classic ECG findings of PE  Understand the pathophysiologic basis  Discuss clinical utility

What are the Classic Findings of PE on ECG?

Case 1  A 54 year-old man  Presents with sudden dyspnea  Hx of recent orthopedic surgery  OE: moderate distress  dyspnea  HR115 RR 36 O2 sats: 92% BP 165/90  His exam was unremarkable except for a casted L leg

Case 1

Findings  Tachycardia  Rightward axis  S1Q3T3  Simultanoeus T-wave inversion in inferior & anteroseptal leads  Incomplete RBBB

What are the Classic Findings of PE on ECG?

“Classic” ECG Abnormalities  Sinus Tachycardia  RV strain pattern  T wave inversions in V1-V4  Rightward axis deviation  Incomplete RBBB  P pulmonalae  S1Q3 or S1Q3T3 pattern  Acute cor pulomnale:  S1Q3T3 pattern, right axis deviation, and RBBB.

 These changes, particularly in combination, are suggestive but not diagnostic of PE  Even pts with massive PE may have only mild, nonspecific ECG changes

In pulmonary embolus, …what is the most common ECG pattern?

Normal ECG  Completely normal  Sinus rhythm between bpm  Normal conduction  Normal axis  Normal P wave, QRS complex, and ST segment/T wave morphologies  An entirely normal ECG is found in10% to 25%* *(Panos, 1988; Hubloue, 1996)

What is the most common ECG abnormality?

Sinus Tachycardia

comment on the conduction

Right Sided Strain Incomplete RBBB   right-sided heart pressures leads to  ventricular afterload  Results in  right-sided myocardial wall tension  The RV is not able to withstand such pressures …it rapidly dilates   chamber size and eventual contractile dysfunction

Case 2  29-year-old woman  Presents with shortness of breath  History: 8 weeks pregnant  On exam: Visibly distressed  HR 110 RR 32 O2 Sat 91% on 5 L BP 80/40

Case 2

Findings  Rate 120  Incomplete RBBB  T wave abnormality

29 F 19 weeks gestation. Presents SOB.

2 hours later

P pulmonalae  Associated with RA enlargement  Incidence: 2% - 30%

Case 3  69-year-old man  Presents with shortness of breath  History of diabetes and hypertension  On exam: Comfortable and alert.  HR 110 RR 32 O2 Sat 97% on 5 L BP 163/107  Exam was otherwise unremarkable

Case 3

Case 3 - findings  Tachycardia  R axis deviation  Incomplete RBBB  S1Q3T3  Simultaneous inversion of T waves in Inferior and anteroseptal leads  p pulmonalae

Ischemia and Infarction   CO compromises both systemic and coronary perfusion   wall tension  Systemic hypotension  Ischemia and infarction  As right-sided ventricular dysfunction worsens, RV infarction and circulatory collapse may occur

Right Axis Deviation  RV enlargement  Negative deflection of lead I  Positive deflection of V6  Left axis deviation – more common (related to underlying dz)  When control for underlying disease – equal incidence (Nielsen, 1989)

McGinn-White Pattern  S1Q3T3  First described in 1935 – 7 pts with massive PE  Since numerous authors have refuted the usefulness  Still classically linked to PE Q: Give a differential diagnosis for S1Q3T3.  PTx  Embolism  AIR, FAT, PE  Cor pulmonalea  Severe Pneumonia  Neoplastic disease

Diagnostic value of ECG  Many studies have been done in patients with confirmed PE  Diagnostic value of ECG can only be determined by applying it to patients with suspected PE …then determine if the test is predictive of PE

 Pts presenting to ED – R/O PE  ECGs were obtained on 189/212 patients  analyzed for 28 features thought to be associated with PE  Only tachycardia and incomplete RBBB were significantly more frequent in patients with PE than those without PE  S1Q3T3  not predictive

Prognosis  What findings were more frequent in pts with fatal outcome?  Atrial arrhythmias  Complete right bundle branch block  Peripheral low voltage  Pseudoinfarction pattern (Q waves) in leads III and aVF  STΔ’s (  or  ) in left precordial leads  29% of pts who exhibited ≥ 1 of these abnormalities did not survive to hospital discharge  11% of the patients without a pathological ECG (Giebel et al., 2005)

Take Home Points  ECG is not a sensitive or specific test for PE  ECG changes are transient  Most common ECG finding – normal  Most common ECG abnormality – sinus tach  Value of ECG in PE  Assessing other etiologies  Prognostic value

References  Panos R J, Barish RA, Whye DW, et al: The electrocardio- graphic manifestations of pulmonary embolism. J Emerg Med 1988; 6:  Hubloue I, Schoors D, Diltoer M, et al: Early electrocardio- graphic signs in acute massive pulmonary embolism. Eur J Emerg Med 1996; 3:  Akula et al. Right-sided EKG in pulmonary embolism. Journal of the National Medical Association (2003).  Nielsen F, Lund O, Ronne K, et al: Changing electrocardio- graphic findings in pulmonary embolism in relation to vascular ob- struction. Cardiol 1989;76:  Geibel et al. Prognostic value of the ECG on admission in patients with acute major pulmonary embolism. European Respiratory Journal (2005)

Right Sided Chest Leads  Increase the sensitivity of ECG  Very small study looked prospectively at 100 pts  Results:  PE present in 20pts  Standard ECG - findings present in 80%  Right-sided ECG – findings present in 100%  qr or qs in V4R, V5R, V6R, increased sensitivity (Akula, 2003)

Case 4  18 year female  Presents with syncope  History: OCP  OE: looks well  HR 102 RR 17 BP 120/76 O2 sats 94%  Otherwise unremarkable

Case 4