Electrocardiography changes and their significance during treatment of patients with intermediate-high and high-risk pulmonary embolism.

Abstract

Electrocardiography (ECG) signs, typical or acute pulmonary embolism, and their changes can be used for the prediction of clinical and haemodynamic outcomes. To study the predictive value of the resolution of admission ECG signs in higher risk pulmonary embolism patients for 30-day survival and for the decrease in right ventricular systolic pressure. We analysed the 12-lead ECGs at admission and daily for the first 5 days after hospitalisation in 110 intermediate-high and high-risk pulmonary embolism patients admitted to the intensive care unit of a single tertiary centre. The predictive value of the resolution of four ECG signs were analysed for 30-day survival and for the changes in right ventricular systolic pressure during hospitalisation: S-wave in the first standard lead, right bundle branch block pattern, S-wave in the aVL lead and negative T-waves in precordial leads. ECG recordings showed the existence of S-wave in the I lead in 71 (64.5%), S-wave in the aVL in 77 (70%), right bundle branch block pattern in 30 (27.3%) and negative T-waves in 66 (60%) patients. All-cause 30-day in-hospital mortality was 13.6%. Among the ECG signs, only the presence of right bundle branch block at admission was significantly associated with 30-day all-cause mortality (hazard ratio (HR) adjusted for age, gender and right ventricular systolic pressure at admission was 7.7, 95% confidence interval (CI) 2.1-27.9; P=0.002). The resolution of three ECG signs during the first 5 days of hospitalisation, S-wave in the I lead (HR 26.4, 95% CI 3.1-226.6; P=0.003), S-wave in the aVL (HR 21.5, 95% CI 2.6-175.3; P=0.004) and right bundle branch block configuration (HR 5.2, 95% CI 1.3-20.8; P=0.020) were associated with 30-day survival. The intermediate-high and high-risk pulmonary embolism patients with S-wave resolution in lead aVL had 0.0% and 7.1% 30-day all-cause mortality, respectively. The patients with resolution of the S-wave in the first lead and in aVL as well as right bundle branch block had more pronounced changes in right ventricular systolic pressure at discharge (27±13 vs. 13±15 mmHg; P=0.011 for S-wave in I lead resolution, 27±12 vs. 15±17 mmHg; P=0.004 for S-wave in aVL resolution and 23±14 vs. 9±14 mmHg; P=0.040 for right bundle branch block resolution) than patients without resolution. Resolution of S-waves and right bundle branch block in ECG correlates with lower all-cause 30-day mortality in intermediate-high and high-risk pulmonary embolism patients. Resolution of S-waves in the first lead and in aVL and right bundle branch block correlates with a decrease of right ventricular systolic pressure.