title: Prognostic value of ECG among patients with acute pulmonary embolism and normal blood pressure.
abstract: OBJECTIVE
  To investigate the prognostic value of electrocardiography (ECG) alone or in combination with echocardiography in patients with acute pulmonary embolism and normal blood pressure.
  
  
  METHODS
  Consecutive adult patients presenting to the emergency department at Azienda Ospedaliero-Universitaria Careggi with the first episode of pulmonary embolism were included. Patients with systolic blood pressure less than 100 mm Hg were excluded. ECG and echocardiography were performed within 1 hour from diagnosis and evaluated in a blinded fashion. Right ventricular strain was diagnosed in the presence of one or more of the following ECG findings: complete or incomplete right ventricular branch block, S1Q3T3, and negative T wave in V1-V4. The main outcome measurement was clinical deterioration or death during in-hospital stay. The association of variables with the main outcome was evaluated by multivariate Cox survival analysis.
  
  
  RESULTS
  A total of 386 patients with proved pulmonary embolism were included in the study; 201 patients (52%) had right ventricular dysfunction according to echocardiography, and 130 patients (34%) showed right ventricular strain. Twenty-three patients (6%) had clinical deterioration or died. At multivariate survival analysis, right ventricular strain was associated with adverse outcome (hazard ratio 2.58; 95% confidence interval, 1.05-6.36) independently of echocardiographic findings. Patients with both right ventricular strain and right ventricular dysfunction (26%) showed an 8-fold elevated risk of adverse outcome (hazard ratio 8.47; 95% confidence interval, 2.43-29.47).
  
  
  CONCLUSIONS
  Right ventricular strain pattern on ECG is associated with adverse short-term outcome and adds incremental prognostic value to echocardiographic evidence of right ventricular dysfunction in patients with acute pulmonary embolism and normal blood pressure.
authors.affiliation: The Emergency Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy. simonevanni@alice.it
authors.forename: Simone
authors.initials: S
authors.lastname: Vanni
authors.forename: Gianluca
authors.initials: G
authors.lastname: Polidori
authors.forename: Ruben
authors.initials: R
authors.lastname: Vergara
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Pepe
authors.forename: Peiman
authors.initials: P
authors.lastname: Nazerian
authors.forename: Federico
authors.initials: F
authors.lastname: Moroni
authors.forename: Emanuele
authors.initials: E
authors.lastname: Garbelli
authors.forename: Fabio
authors.initials: F
authors.lastname: Daviddi
authors.forename: Stefano
authors.initials: S
authors.lastname: Grifoni
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001794:Blood Pressure / Q000502:physiology; D004452:Echocardiography / Q000379:methods; D004562:Electrocardiography / Q000379:methods*; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage; D006493:Heparin / Q000008:administration & dosage; D006801:Humans; D008297:Male; D008875:Middle Aged; D009206:Myocardium / Q000737:chemistry; D011379:Prognosis; D011655:Pulmonary Embolism / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000188:drug therapy / Q000503:physiopathology*; D019210:Troponin I / Q000032:analysis; D018497:Ventricular Dysfunction, Right / Q000000981:diagnostic imaging / Q000503:physiopathology; D055815:Young Adult
chemical_list: D005343:Fibrinolytic Agents; D019210:Troponin I; D006493:Heparin