Is it possible to use standard electrocardiography for risk assessment of patients with pulmonary embolism?
BACKGROUND
Risk stratification of patients with acute pulmonary embolism (APE) is crucial for appropriate treatment selection. Shock and hypotonia are known indications for aggressive management. However, in the haemodynamically stable group the best prognosis strategy is still being sought. Acute pulmonary embolism often provokes changes in electrocardiography recordings (ECG).


OBJECTIVE
To assess whether ECG features recorded on admission can be useful for risk stratification during hospitalisation.


METHODS
We analysed 12-lead ECG and echocardiography of 56 patients (22 males, age: 64.3 +/- 17.9 years) with diagnosed APE. The diagnosis of APE was confirmed by spiral computer tomography. The ECG analysis was based on the 21-point ECG score including: the presence of tachycardia (> 100 beats/min), right bundle branch block, negative S waves in lead I, negative Q or T waves in lead III, S1Q3T3 complex and depth of negative T waves in leads V1-V4. ECG features were scored from 0 to 21 points. Complicated in-hospital course was defined as need for vasopressor, thrombolysis, embolectomy or resuscitation and the presence of shock index > 1 (heart rate/systolic blood pressure).


RESULTS
Four (7.1%) patients died during hospitalisation and in 8 (14.3%) others complications occurred. Patients with complications had higher mean sum of 21-ECG score compared to subjects with uneventful course [8 (1-17) vs. 3 (0-18); p = 0.04]. Right ventricular contractility dysfunction (RVD) in echocardiography was found in 13 (23.2%) patients, who had higher ECG score compared to patients without RVD [8 (3-17) vs. 2 (0-18); p = 0.004]. The area under the ROC curve to assess the usefulness of 21-ECG score to predict RVD was 0.794 (95% CI 0.665-0.891) and for PPH 0.727 (95% CI 0.591-0.837). The sensitivity and specificity, positive and negative predictive value for the value > 3 points in 21-ECG score to predict RVD were: 92, 65, 44, 97% and for PPH: 75, 46, 19, 92%, respectively.


CONCLUSIONS
21-ECG score is a simple and cheap method which can be used to predict RVD and serious complications in patients with APE. A value Ł 3 points in the 21-ECG score can exclude RVD with high probability and limit the need of echocardiography to 23% of haemodynamically stable patients.
Kostrubiec
Maciej
M
Department of Internal Medicine and Cardiology, Medical University, Warsaw, Poland. maciej.kostrubiec@wum.edu.pl
Hrynkiewicz
Anna
A
Pedowska-Włoszek
Justyna
J
Pacho
Szymon
S
Ciurzyński
Michał
M
Jankowski
Krzysztof
K
Koczaj-Bremer
Magdalena
M
Wojciechowski
Artur
A
Pruszczyk
Piotr
P
D000368:Aged; D000369:Aged, 80 and over; D004562:Electrocardiography / Q000379:methods*; D005260:Female; D006801:Humans; D007297:Inpatients / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D011044:Poland; D011237:Predictive Value of Tests; D011655:Pulmonary Embolism / Q000150:complications / Q000175:diagnosis*; D018570:Risk Assessment / Q000379:methods; D012680:Sensitivity and Specificity; D036542:Tomography, Spiral Computed; D018497:Ventricular Dysfunction, Right / Q000175:diagnosis* / Q000209:etiology