12-Lead ECG Findings of Pulmonary Hypertension Occur More Frequently in Emergency Department Patients With Pulmonary Embolism Than in Patients Without Pulmonary Embolism
Received 7 April 2009; received in revised form 25 June 2009; accepted 24 July 2009. published online 22 September 2009. Corrected Proof
Study objective
Acute pulmonary embolism can produce abnormalities on ECG that reflect severity of pulmonary hypertension. Early recognition of these findings may alter the estimated pretest probability of pulmonary embolism and prompt more aggressive treatment before hemodynamic instability ensues, but it is first important to test whether these findings are specific to patients with pulmonary embolism. We hypothesize that ECG findings consistent with pulmonary hypertension would be observed more frequently in patients with pulmonary embolism.
Methods
Secondary analysis of a prospective, observational cohort of emergency department patients who were tested for pulmonary embolism. ECGs were ordered at clinician's discretion and interpreted at presentation.
Results
Six thousand forty-nine patients had an ECG, 354 (5.9%) of whom were diagnosed with pulmonary embolism. The frequency, positive likelihood ratio (LR+) and 95% confidence interval (CI) of each predictor were as follows: S1Q3T3 8.5% with pulmonary embolism versus 3.3% without pulmonary embolism (LR+ 3.7; 95% CI 2.5 to 5.4); nonsinus rhythm, 23.5% versus 16.6% (LR+ 1.4; 95% CI 1.2 to 1.7); inverted T waves in V1 to V2, 14.4% versus 8.1% (LR+ 1.8; 95% CI 1.3 to 2.3); inversion in V1 to V3, 10.5% versus 4.0% (LR+ 2.6; 95% CI 1.9 to 3.6); inversion in V1 to V4, 7.3% versus 2.0% (LR+ 3.7; 95% CI 2.4 to 5.5); incomplete right bundle branch block, 4.8% versus 2.8% (LR+ 1.7; 95% CI 1.0 to 2.7); tachycardia (pulse rate >100 beats/min), 28.8% versus 15.7% (LR+ 1.8; 95% CI 1.5 to 2.2). Likelihood ratios and specificities were similar when patients with previous cardiopulmonary disease were excluded from analysis.
Conclusion
Findings of acute pulmonary hypertension were infrequent overall but were observed more frequently in patients with the final diagnosis of pulmonary embolism compared with patients who do not have pulmonary embolism.
aDepartment of Emergency Medicine, Carolinas Medical Center, Charlotte, NC
bDepartment of Emergency Medicine, Northwestern University, Chicago, IL
cDepartment of Emergency Medicine, Massachusetts General Hospital, Boston, MA
dDepartment of Surgery, University of Colorado, Denver, CO
eDepartment of Emergency Medicine, St. Vincent Mercy Medical, Toledo, OH
fDepartment of Emergency Medicine, Mayo Clinic, Scottsdale, AZ
gDepartment of Emergency Medicine, Baystate Medical Center, Springfield, MA
Address for reprints: Jeffrey A. Kline, MD, Emergency Medicine Research, Department of Emergency Medicine, Carolinas Medical Center, PO Box 32861, Charlotte, NC 28323-2861; 704-355-7092, fax 704-355-7047
Supervising editor: Allan B. Wolfson, MD
Author contributions: MRM analyzed the data and drafted the article. DMC, CK, KEN, MCP, PBR, HAS, and JAK participated in data collection and revision of the original draft of the article. JAK conceived the study, obtained funding, and takes responsibility for the paper as a whole.
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. Supported by grants from the National Institutes of Health, R41HL074415 and R42HL074415, K23HL077404 and R01 HL074384.
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