Electrocardiographic Findings in Patients with Pulmonary Embolism Sevket Balta M.D., Sait Demırkol M.D, Murat Unlu M.D, Cengiz Ozturk M.D, Zekeriya Arslan M.D, Mustafa Demır M.D. PII: DOI: Reference:
S0735-6757(15)00148-5 doi: 10.1016/j.ajem.2015.03.004 YAJEM 54847
To appear in:
American Journal of Emergency Medicine
Received date: Accepted date:
1 March 2015 3 March 2015
Please cite this article as: M.D. Sevket Balta, Demırkol Sait, Unlu Murat, Ozturk Cengiz, Arslan Zekeriya, Demır Mustafa, Electrocardiographic Findings in Patients with Pulmonary Embolism, American Journal of Emergency Medicine (2015), doi: 10.1016/j.ajem.2015.03.004
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Electrocardiographic Findings in Patients with Pulmonary Embolism
*Sevket BALTA, M.D.
RI P
T
**Sait DEMIRKOL, M.D, Associate Professor of Cardiology **Murat UNLU, M.D, Associate Professor of Cardiology
SC
**Cengiz OZTURK, M.D, Associate Professor of Cardiology
**Mustafa DEMIR, M.D.
MA NU
**Zekeriya ARSLAN, M.D, Associate Professor of Cardiology
ED
* Department of Cardiology, Eskişehir Military Hospital, Eskişehir/TURKEY
CE
PT
** Department of Cardiology, Gulhane Medical Academy Ankara, TURKEY
Address for correspondence and reprints Dr Sevket BALTA
AC
Department of Cardiology
Eskisehir Military Hospital, Vişnelik Mah., Atatürk Cd. 26020 Akarbaşı/ Eskişehir, Turkey Tel: +90 222 220 45 30 Fax: +90 222 230 34 33 E-mail: [email protected] There is no conflict of interests
ACCEPTED MANUSCRIPT Electrocardiographic Findings in Patients with Pulmonary Embolism
T
Dear Editor,
RI P
We have read the recently published article entitled ‘‘Electrocardiographic abnormalities in patients with acute pulmonary embolism(APE) complicated by cardiogenic shock(CS)” by
SC
Kukla and coworkers(1). In that very well-designed and presented study by Kukla and
MA NU
coworkers tried to compare electrocardiography (ECG) parameters in patients with APE presenting with or without CS. They have concluded that in patients with APE, low QRS voltage, RBBB, and ST-segment elevation in lead V1 were associated with CS.
ED
Acute pulmonary embolism is an important cardiovascular disease with a higher mortality rate(2). Numerous ECG abnormalities have been reported in patients with PE. Pulmonary
PT
embolism risk stratification may allow early hospital discharge and outpatient treatment for
CE
low-risk patients. Some predictors of adverse early life outcomes after PE have been identified(3). However, investigation of the relation of ECG abnormalities patients to
AC
cardiogenic shock has been debated. Although it is the most frequent ECG abnormality, sinus tachycardia lacks specificity. However, ECG findings are more specific in patients with severe PE (such as the classic S1Q3T3 pattern). In the case of massive and submassive PE, anterior and inferior T-wave inversion is the most frequent associated ECG finding. Serial ECG evaluation should be performed in such patients as changes and resolution of abnormalities may have prognostic implications. In a previous study, the authors assessed further the relation of ECG changes in acute PE to right ventricle(RV) cavity enlargement (dilation). Normal ECG findings were less prevalent in patients with PE and RV enlargement than those with PE and no RV enlargement. One or more of the traditional ECG manifestations of acute cor pulmonale (S1Q3T3, complete right bundle branch block(RBBB),
ACCEPTED MANUSCRIPT P pulmonale, or right axis deviation) was found in 18 of 141 patients (13%) with RV enlargement and 13 of 148 (8.8%) with a normal size RV(4). In present study, the authors(1)
T
siad that all ECGs were examined by a single cardiologist who was blinded to all other
RI P
clinical data. It is important that ECG paremeters should be determined by at least two cardiologists. So, it would be better to give interobserver and intraobserver variability for
SC
ECG parameters in the current study. Finally, laboratory measurements as troponin I elevation in PE patients showed a clear correlation with greater risk for clinical complications and in-
MA NU
hospital mortality(5). In view of its clinical usefulness and prognostic value, troponin levels should be correlated ECG parameters in all patients with this pathology.
As a conclusion, in patients with APE, low QRS voltage, RBBB, and ST-segment elevation
ED
in lead V1 were associated with CS as presented in current study, however, one should be
PT
kept in mind that CS should be investigated in many conditions and parameters.
CE
References
Kukla P, McIntyre WF, Fijorek K, Mirek-Bryniarska E, Bryniarski L, Krupa E, et al. Electrocardiographic abnormalities in patients with acute pulmonary embolism complicated by cardiogenic shock. Am J Emerg Med. 2014 Jun;32(6):507–10.
2.
Balta S, Karademir I, Demir M, Ozturk C, Celik T, Demirkol S. Red cell distribution width in pulmonary embolism. Wien Klin Wochenschr. 2014 Sep;126(17-18):553–4.
3.
Demirkol S, Balta Ş. Right ventricular functions in pulmonary embolism. Anadolu Kardiyol Derg. 2012 Dec;12(8):666–7.
4.
Stein PD, Matta F, Sabra MJ, Treadaway B, Vijapura C, Warren R, et al. Relation of electrocardiographic changes in pulmonary embolism to right ventricular enlargement. Am J Cardiol. 2013 Dec 15;112(12):1958–61.
5.
Margato R, Carvalho S, Ribeiro H, Mateus P, Fontes P, Moreira JI. Cardiac troponin I levels in acute pulmonary embolism. Rev Port Cardiol. 2009 Nov;28(11):1213–22.
AC
1.
S0735-6757(15)00148-5 doi: 10.1016/j.ajem.2015.03.004 YAJEM 54847
To appear in:
American Journal of Emergency Medicine
Received date: Accepted date:
1 March 2015 3 March 2015
Please cite this article as: M.D. Sevket Balta, Demırkol Sait, Unlu Murat, Ozturk Cengiz, Arslan Zekeriya, Demır Mustafa, Electrocardiographic Findings in Patients with Pulmonary Embolism, American Journal of Emergency Medicine (2015), doi: 10.1016/j.ajem.2015.03.004
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Electrocardiographic Findings in Patients with Pulmonary Embolism
*Sevket BALTA, M.D.
RI P
T
**Sait DEMIRKOL, M.D, Associate Professor of Cardiology **Murat UNLU, M.D, Associate Professor of Cardiology
SC
**Cengiz OZTURK, M.D, Associate Professor of Cardiology
**Mustafa DEMIR, M.D.
MA NU
**Zekeriya ARSLAN, M.D, Associate Professor of Cardiology
ED
* Department of Cardiology, Eskişehir Military Hospital, Eskişehir/TURKEY
CE
PT
** Department of Cardiology, Gulhane Medical Academy Ankara, TURKEY
Address for correspondence and reprints Dr Sevket BALTA
AC
Department of Cardiology
Eskisehir Military Hospital, Vişnelik Mah., Atatürk Cd. 26020 Akarbaşı/ Eskişehir, Turkey Tel: +90 222 220 45 30 Fax: +90 222 230 34 33 E-mail: [email protected] There is no conflict of interests
ACCEPTED MANUSCRIPT Electrocardiographic Findings in Patients with Pulmonary Embolism
T
Dear Editor,
RI P
We have read the recently published article entitled ‘‘Electrocardiographic abnormalities in patients with acute pulmonary embolism(APE) complicated by cardiogenic shock(CS)” by
SC
Kukla and coworkers(1). In that very well-designed and presented study by Kukla and
MA NU
coworkers tried to compare electrocardiography (ECG) parameters in patients with APE presenting with or without CS. They have concluded that in patients with APE, low QRS voltage, RBBB, and ST-segment elevation in lead V1 were associated with CS.
ED
Acute pulmonary embolism is an important cardiovascular disease with a higher mortality rate(2). Numerous ECG abnormalities have been reported in patients with PE. Pulmonary
PT
embolism risk stratification may allow early hospital discharge and outpatient treatment for
CE
low-risk patients. Some predictors of adverse early life outcomes after PE have been identified(3). However, investigation of the relation of ECG abnormalities patients to
AC
cardiogenic shock has been debated. Although it is the most frequent ECG abnormality, sinus tachycardia lacks specificity. However, ECG findings are more specific in patients with severe PE (such as the classic S1Q3T3 pattern). In the case of massive and submassive PE, anterior and inferior T-wave inversion is the most frequent associated ECG finding. Serial ECG evaluation should be performed in such patients as changes and resolution of abnormalities may have prognostic implications. In a previous study, the authors assessed further the relation of ECG changes in acute PE to right ventricle(RV) cavity enlargement (dilation). Normal ECG findings were less prevalent in patients with PE and RV enlargement than those with PE and no RV enlargement. One or more of the traditional ECG manifestations of acute cor pulmonale (S1Q3T3, complete right bundle branch block(RBBB),
ACCEPTED MANUSCRIPT P pulmonale, or right axis deviation) was found in 18 of 141 patients (13%) with RV enlargement and 13 of 148 (8.8%) with a normal size RV(4). In present study, the authors(1)
T
siad that all ECGs were examined by a single cardiologist who was blinded to all other
RI P
clinical data. It is important that ECG paremeters should be determined by at least two cardiologists. So, it would be better to give interobserver and intraobserver variability for
SC
ECG parameters in the current study. Finally, laboratory measurements as troponin I elevation in PE patients showed a clear correlation with greater risk for clinical complications and in-
MA NU
hospital mortality(5). In view of its clinical usefulness and prognostic value, troponin levels should be correlated ECG parameters in all patients with this pathology.
As a conclusion, in patients with APE, low QRS voltage, RBBB, and ST-segment elevation
ED
in lead V1 were associated with CS as presented in current study, however, one should be
PT
kept in mind that CS should be investigated in many conditions and parameters.
CE
References
Kukla P, McIntyre WF, Fijorek K, Mirek-Bryniarska E, Bryniarski L, Krupa E, et al. Electrocardiographic abnormalities in patients with acute pulmonary embolism complicated by cardiogenic shock. Am J Emerg Med. 2014 Jun;32(6):507–10.
2.
Balta S, Karademir I, Demir M, Ozturk C, Celik T, Demirkol S. Red cell distribution width in pulmonary embolism. Wien Klin Wochenschr. 2014 Sep;126(17-18):553–4.
3.
Demirkol S, Balta Ş. Right ventricular functions in pulmonary embolism. Anadolu Kardiyol Derg. 2012 Dec;12(8):666–7.
4.
Stein PD, Matta F, Sabra MJ, Treadaway B, Vijapura C, Warren R, et al. Relation of electrocardiographic changes in pulmonary embolism to right ventricular enlargement. Am J Cardiol. 2013 Dec 15;112(12):1958–61.
5.
Margato R, Carvalho S, Ribeiro H, Mateus P, Fontes P, Moreira JI. Cardiac troponin I levels in acute pulmonary embolism. Rev Port Cardiol. 2009 Nov;28(11):1213–22.
AC
1.
