The best predictor for right ventricular dysfunction in acute pulmonary embolism: comparison between electrocardiography and biomarkers

Abstract

Background and objectives: Right ventricular (RV) dysfunction is associated with a poor prognosis in patients with an acute pulmonary embolism (APE). We studied the role of electrocardiography and biomarkers for early detection and recovery of right ventricular dysfunction (RVD) in APE.

Subjects and methods: The medical records of 48 consecutive patients diagnosed with APE using CT-angiography, at the Kangdong Sacred Heart Hospital, between January 2004 and February 2008 were reviewed retrospectively. RVD was assessed by serial echocardiography (ECG). Patients with one of the following were considered to have RVD: 1) RV dilatation (enddiastolic diameter >30 mm in the parasternal long axis view), 2) RV free wall hypokinesia, and 3) paradoxical septal systolic motion. We compared the electrocardiographic findings and the biomarkers for the early detection of RVD.

Results: The electrocardiographic findings showed T-wave inversion (TWI) in leads V1 to V3 with a sensitivity of 75% and a specificity of 95%, and a diagnostic accuracy of 80% for the detection of RVD, with positive and negative predictive values of 95.5% and 73.1%, respectively; these results were better than the biomarkers such as cardiac enzymes or B-type natriuretic peptide (BNP) for the early detection of RVD. TWIs persisted throughout the period of RVD, in contrast to a transient S1Q3T3 pattern detected during the acute phase only.

Conclusion: TWIs in leads V1 to V3 had the greatest sensitivity and diagnostic accuracy for early detection of RVD, and normalization of the TWIs was associated with recovery of RVD in APE.

Keywords: Electrocardiography; Pulmonary embolism; Ventricular dysfunction, right.

Fig. 1

Representative example of serial changes on the electrocardiogram (ECG) of a 67-year-old patient with a massive pulmonary embolism during admission for multiple rib fractures. Normal ECG on admission (A) changed with appearance of complete right bundle branch block (RBBB) and sinus tachycardia on day 4 when the patient presented with sudden dyspnea and shock (B). Panel C shows T-wave inversions (TWIs) in leads V_1-4, which followed the disappearance of RBBB after thrombolytic therapy on the day of the event with right ventricular enlargement and hypokinesis on ECG. Note the normalized TWIs in the precordial leads on day 8 (D), and the ECG performed on the same day showed improvement of right ventricular dysfunction.