Electrocardiogram Patterns during Hemodynamic Instability in Patients with Acute Pulmonary Embolism

Zhong-qun, Zhan; Chong-quan, Wang; Nikus, Kjell; He, Chuan; Wang, Jin; Shan, Mingguang; Dong, Xiongjian

doi:10.1111/anec.12163

Cited by 42 publications

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“…We have described that 3 distinct ischemic ECG patterns represent different manifestations of RV and LV transmural and subendocardial ischemia [9]. According to our results, these ECG patterns are frequent (89%) in APE patients with STDV and NTW.…”

Section: Discussionsupporting

confidence: 59%

“…However, the literature suggests that the distribution of STDV has consistent regularity and mechanisms [6][7][8][9][13][14][15][16]. STE in leads V1, III, aVR and STD in leads I and V4/ V5-V6 are frequently observed in APE [6,7,9].…”

Section: Discussionmentioning

confidence: 97%

“…According to our results, these ECG patterns are frequent (89%) in APE patients with STDV and NTW. The mechanism of the ischemic patters has been attributed to hypotension, hypoxemia, pulmonary artery hypertension, and catecholamine surge [9,14].…”

Section: Discussionmentioning

confidence: 99%

“…2C). The other abnormal ECG criteria associated with APE are identical to our previous study [9]. Relatively normal ECG was defined as an ECG without any STDV, abnormal QRS morphology in lead V1 (notched S wave, right bundle branch block [RBBB] or QR sign) and S1Q3T3.…”

Section: Electrocardiogrammentioning

confidence: 97%

“…STDV could occur in 3 specific ischemic patterns: (i) left ventricular (LV) subendocardial ischemic pattern; (ii) RV transmural ischemic pattern; and (iii) LV subendocardial plus RV transmural ischemic pattern [9].…”

Section: Introductionmentioning

confidence: 99%

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Significance of ST-segment deviation in patients with acute pulmonary embolism and negative T waves

et al. 2015

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Background: Common electrocardiogram (ECG) manifestations in acute pulmonary embolism (APE) include ST-segment deviation (STDV) along with negative T-waves (NTW). STDV could occur in 3 typical ischemic patterns: (i) the left ventricular (LV) subendocardial ischemic pattern; (ii) the right ventricular (RV) transmural ischemic pattern; and (iii) the LV intensification of therapy, and death compared to patients without STDV (p = 0.001 for each variable). The majority (89%) of the patients with STDV presented with 1 of the 3 typical ischemic ECG patterns. LV subendocardial ischemic pattern (OR = 4.963, p = 0.004), RV transmural ischemic pattern (OR = 3.128, p = 0.021) and LV subendocardial plus RV transmural ischemic pattern (OR = 3.036, p = 0.017) independently predicted the need to intensify therapy. RV transmural ischemic pattern (OR = 4.227, p = 0.031) and LV subendocardial plus RV transmural ischemic pattern (OR = 4.022, p = 0.032) (Cardiol J 2015; 22, 5: 583-589)

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Section: Discussionsupporting

confidence: 59%

Section: Discussionmentioning

confidence: 97%

Section: Discussionmentioning

confidence: 99%

Section: Electrocardiogrammentioning

confidence: 97%

Section: Introductionmentioning

confidence: 99%

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Significance of ST-segment deviation in patients with acute pulmonary embolism and negative T waves

et al. 2015

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The Role of Echocardiography in Identifying ST-Segment Elevation Mimics

Jolobe

2022

JAMA Intern Med

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In Reply We appreciate the comments of Drs Hennessey and Funck-Brentano in response to our recent comparative effectiveness research article. 1 Dr Hennessey raised the question of the effect of endogenous thyroid hormone production after switching. We agree that this is important to consider. Although we planned to analyze switching among patients after total thyroid removal (no endogenous thyroid production), our study was underpowered to assess this. However, we conducted a sensitivity analysis among patients receiving daily levothyroxine dosages higher than 100 μg. This group likely represents patients with low endogenous thyroid production because a daily dosage of more than 100 μg of levothyroxine may suppress the thyroxine produced in the thyroid gland. In this subgroup, mean (SD) thyrotropin (TSH) levels were similar among switchers (2.53 [6.40] mIU/L) and nonswitchers (2.53 [3.09] mIU/L; P > .99). Dr Funck-Brentano noted that the standard deviation was more than 2-fold greater among switchers than nonswitchers, suggesting that the latter group might have experienced greater variation in thyroid hormone levels following generic switches than patients receiving lower levothyroxine dosages. However, standard deviation differences may have been driven simply by the smaller sample size of this subgroup, 2 which was 7 times smaller than the subgroup of patients treated with daily levothyroxine dosages of no more than 100 μg.Dr Hennessey referenced 2 studies to support the European Thyroid Association's call for caution and thyroid testing after switching from 1 product to another. This is an important point because it highlights the importance of the applicability of results to other geographic areas under other drug approval processes. Our results are applicable only to the US and for studies regulated by the US Food and Drug Administration. Each regulatory agency has its bioequivalent standard methods and is expected to conduct comparative effectiveness research studies applicable to their products and populations.Finally, Dr Funck-Brentano highlighted the importance of considering intraindividual TSH changes rather than populationlevel TSH changes when translating findings into practice. We agree; accordingly, we examined interindividual differences using an unpaired test with a robust estimate for variance. For intraindividual differences, we examined the change in TSH for each individual before and after the index date and averaged these mean changes for each group. We believe that these data support decision-making for patients like those included in our study. To further explore the role of generic levothyroxine switching to inform decision-making for each individual, an n-of-1 trial would be the correct study design.

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The value of electrocardiography in prognosticating clinical deterioration and mortality in acute pulmonary embolism: A systematic review and meta‐analysis

Qaddoura

Digby

Kabali

et al. 2017

Clinical Cardiology

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The role of electrocardiography (ECG) in prognosticating pulmonary embolism (PE) is increasingly recognized. ECG is quickly interpretable, noninvasive, inexpensive, and available in remote areas.We hypothesized that ECG can provide useful information about PE prognostication. We searched MEDLINE, EMBASE, Google Scholar, Web of Science, abstracts, conference proceedings, and reference lists through February 2017. Eligible studies used ECG to prognosticate for the main outcomes of death and clinical deterioration or escalation of therapy. Two authors independently selected studies; disagreement was resolved by consensus. Ad hoc piloted forms were used to extract data and assess risk of bias. We used a random-effects model to pool relevant data in meta-analysis with odds ratios (ORs) and 95% confidence intervals (CIs); all other data were synthesized qualitatively. Statistical heterogeneity was assessed using the I 2 value. We included 39 studies (9198 patients) in the systematic review. There was agreement in study selection (κ:0.91, 95% CI: 0.86-0.96). Most studies were retrospective; some did not appropriately control for confounders. ECG signs that were good predictors of a negative outcome included S1Q3T3 (OR:3.38, 95% CI: 2.46-4.66, P < 0.001), complete right bundle branch block (OR: 3.90, 95% CI: 2.46-6.20, P < 0.001), T-wave inversion (OR: 1.62, 95% CI: 1.19-2.21, P = 0.002), right axis deviation (OR: 3.24, 95% CI: 1.86-5.64, P < 0.001), and atrial fibrillation (OR: 1.96, 95% CI: 1.45-2.67, P < 0.001) for in-hospital mortality. Several ischemic patterns also were significantly predictive.Our conclusion is that ECG is potentially valuable in prognostication of acute PE.

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Electrocardiogram Patterns during Hemodynamic Instability in Patients with Acute Pulmonary Embolism

Abstract: Hemodynamic instability in acute pulmonary embolism is reflected by signs of myocardial ischemia combined with the right ventricular strain pattern in the 12-lead ECG.

Cited by 42 publications

References 28 publications

Significance of ST-segment deviation in patients with acute pulmonary embolism and negative T waves

Significance of ST-segment deviation in patients with acute pulmonary embolism and negative T waves

The Role of Echocardiography in Identifying ST-Segment Elevation Mimics

The value of electrocardiography in prognosticating clinical deterioration and mortality in acute pulmonary embolism: A systematic review and meta‐analysis

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