EKG Rounds

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EKG Rounds

• Mark Bromley PGY3

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Objectives

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

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What are the Classic Findings of PE on ECG?
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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

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Case 1
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Findings

• Tachycardia
• Rightward axis
• S1Q3T3
• Simultanoeus T-wave inversion in inferior
  anteroseptal leads
• Incomplete RBBB

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What are the Classic Findings of PE on ECG?
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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.

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

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

• Completely normal
• Sinus rhythm between 60-100 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)
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What is the most common ECG abnormality?
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Sinus Tachycardia
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comment on the conduction
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Right Sided StrainIncomplete 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

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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

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Case 2
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Findings

• Rate 120
• Incomplete RBBB
• T wave abnormality

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29 F 19 weeks gestation. Presents SOB.
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2 hours later
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P pulmonalae

• Associated with RA enlargement
• Incidence 2 - 30

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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

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Case 3
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Case 3 - findings

• Tachycardia
• R axis deviation
• Incomplete RBBB
• S1Q3T3
• Simultaneous inversion of T waves in Inferior and
  anteroseptal leads
• p pulmonalae

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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

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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)
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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

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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

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• 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

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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
• ST?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)
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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

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References

• Panos R J, Barish RA, Whye DW, et al The
  electrocardio- graphic manifestations of
  pulmonary embolism. J Emerg Med 1988 6301-7
• Hubloue I, Schoors D, Diltoer M, et al Early
  electrocardio- graphic signs in acute massive
  pulmonary embolism. Eur J Emerg Med 1996
  3199-204
• 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 198976274-284
• Geibel et al. Prognostic value of the ECG on
  admission in patients with acute major pulmonary
  embolism. European Respiratory Journal (2005)

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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)
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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

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Case 4