RECOGNITION OF ISCHEMIC ELECTROCARDIOGRAPHIC PATTERNS AS MARKERS OF INCREASED RISK IN PATIENTS WITH ACUTE PULMONARY EMBOLISM

Abstract

Current international recommendations on the management of acute pulmonary embolism (APE) divide patients into 3 risk categories: high, intermediate and low. Patients said to be at intermediate risk are those with positive cardiac biomarkers and evidence of right ventricular dysfunction (RVD). Mortality has previously been estimated as ranging from as low as 3% to as high as 15% in this intermediate risk group. The aim of this study was to explore the utility of pre-defined ischemic ECG patterns to more precisely estimate the risk (complications or death) of APE patients identified as intermediate risk by current standards. The study group consisted of 500 consecutive patients (290 females), with a mean age 66.3 ±15.2 years. Of these patients, 245 (72.8%) patients were initially classified as intermediate-risk. Four ischemic ECG patterns were studied: i) ST Ischemic Pattern (STIP): defined as the presence of at least one lead with ST-segment elevation out of leads III, aVR and V1-V4 OR ST-segment depression in at least 2 lateral leads (I, aVL, V4-V6); ii) Global Ischemic Pattern (GIP): defined as the presence of at least one lead with ST-segment elevation out of leads III, aVR and V1-V4 AND ST-segment depression in at least 2 lateral leads (I, aVL, V4-V6); iii) Negative T-Wave Pattern (NTW): defined as patients not meeting the criteria for GIP or STIP and with negative T-waves in at least 2 of the inferior leads (II, III, aVF) AND in at least 2 of the right precordial leads (V1-V4); iv) No ischemic changes: ECGs not meeting any of the other 3 criteria. Predictors of death in univariate analysis included elevated troponin concentration (OR 6.8 [95% CI, 1.28-169; p = 0.02]) and the STIP ischemic ECG pattern: (OR 6.3 [95% CI, 1.6-46.0; p = 0.007]). Patients with RVD who had STIP experienced a significantly higher mortality rate compared to RVD patients who did not have STIP; (11.4% vs. 1.6%, OR 7.26, [95% CI, 1.82-52.8; p = 0.004]). In patients with STIP as compared to those without, the rate of death (OR 6.35; p = 0.007) and the rate of complications (OR 4.19; p = 0.002) were significantly higher. Neither the presence of NTW nor GIP pattern was associated with a worse prognosis. In patients with APE, an ischemic ECG pattern on hospital admission, when identified in addition to classic risk markers, is an independent risk factor for worse in-hospital outcomes.