Pulmonary embolism electrocardiogram

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Editor(s)-In-Chief: C. Michael Gibson, M.S., M.D. [1], The APEX Trial Investigators; Associate Editor(s)-in-Chief:  Rim Halaby, M.D. [2]

## Overview

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The electrocardiogram (ECG) in the cases of pulmonary embolism (PE) is often abnormal; however, the ECG abnormalities are neither sensitive nor specific.[1][2] Some of the most common ECG abnormalities in PE include T wave inversion in the anterior leads and sinus tachycardia.[3][4][2] The ECG abnormalities reported in PE are also present in a variety of other conditions rendering the utility of ECG for the diagnosis of PE limited. Nevertheless, an ECG is routinely performed in all patients with suspected PE in order to rule out other differential diagnoses such as myocardial infarction.

## Electrocardiogram

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Various ECG abnormalities are reported in PE patients; however, the ECG findings lack sensitivity and specificity for PE. T wave inversion in the anterior leads has been reported in many studies as the most common ECG finding among patients with PE, particularly massive PE.[3][4][2] In addition, the development of a Qr wave in lead V1 has been reported as as an independent correlate of adverse prognosis.[5]

### Complete List of ECG Findings

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Shown below is a list of ECG findings in PE:[6][3][4][2]

* T wave inversion in the anterior leads (one of the most common findings, particularly in massive PE)
* Sinus tachycardia (one of the most common findings)
* Incomplete RBBB
* Complete RBBB
* S1Q3T3
* Right axis deviation
* ST segment and T wave non specific changes[7]
* P pulmonale[7]
* Low QRS voltage
* Normal heart rhythm
* ST elevation (rare)[8]
* Q waves in the anterior leads (rare)[9]

Shown below is a table summarizing the rate of occurrence of a variety of ECG findings in PE according to three different studies.

ECG Findings | Study 1[3] | Study 2[4] | Study 3[2]

|
|
|

T wave inversion | 68% | 42% | 44.4%
Sinus tachycardia | 26% | 69% | 42.2%
RBBB | 22% | 15% | 4.4%-6.7%
S1Q3T3 | 50% | 12% | 11.6%
P pulmonale | 5% | 6% | 2.2%
Normal heart rhythm | 9% | 13% | \-

### T Wave Inversion

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T wave inversion in the anterior leads has been reported in many studies as the most common ECG finding among patients with PE, particularly massive PE.[3][4][2] T wave inversion in the anterior leads represent reciprocal changes related to infero-posterior ischemia due to compression of the right coronary artery (RCA), caused by pressure overload in the right ventricle following an acute PE.[10]

### Cor Pulmonale and Right Heart Strain

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Signs of right heart strain or acute cor pulmonale may be present in patients with a massive PE. The classic sign S1Q3T3 is characterized by the presence of a large S wave in lead I, a large Q wave in lead III and an inverted T wave in lead III .[11][12] S1Q3T3 is a sign of acute cor pulmonale that can be present in conditions other than PE.

## Electrocardiographic Examples

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Shown below is an EKG of a patient with a pulmonary embolism:

ECG

Copyleft image obtained courtesy of ECGpedia ecgpedia

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Shown below is an EKG of a patient with a pulmonary embolism:

ECG of a patient with pulmonary embolism showing sinus tachycardia and right axis deviation.

Copyleft image obtained courtesy of ECGpedia ecgpedia

* * *

Shown below is an EKG of a patient with a pulmonary embolism:

ECG of a patient with pulmonary embolism showing S1-Q3 and signs of right frontal axis deviation.

Image courtesy of Dr Jose Ganseman Dr Ganseman's webpage: An ultimate source of EKG

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Shown below is an EKG of a patient with a pulmonary embolism:

ECG of patient with pulmonary embolism showing S1 Q3 T3, Right bundle branch block pattern and flipped anterior T waves.

Image obtained courtesy of Amal Mattu, M.D.

* * *

Shown below is an EKG of a patient with a pulmonary embolism:

A common ECG finding in pulmonary embolism is anterior T wave inversion.

Image obtained courtesy of Amal Mattu, M.D.

* * *

## References

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1. ↑ Geibel A, Zehender M, Kasper W, Olschewski M, Klima C, Konstantinides SV (2005). "Prognostic value of the ECG on admission in patients with acute major pulmonary embolism". Eur Respir J. 25 (5): 843–8. doi:10.1183/09031936.05.00119704. PMID 15863641.CS1 maint: Multiple names: authors list (link)
2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 Rodger M, Makropoulos D, Turek M, Quevillon J, Raymond F, Rasuli P; et al. (2000). "Diagnostic value of the electrocardiogram in suspected pulmonary embolism". Am J Cardiol. 86 (7): 807–9, A10. PMID 11018210.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
3. ↑ 3.0 3.1 3.2 3.3 3.4 Ferrari E, Imbert A, Chevalier T, Mihoubi A, Morand P, Baudouy M (1997). "The ECG in pulmonary embolism. Predictive value of negative T waves in precordial leads--80 case reports". Chest. 111 (3): 537–43. PMID 9118684.CS1 maint: Multiple names: authors list (link)
4. ↑ 4.0 4.1 4.2 4.3 4.4 Stein PD, Dalen JE, McIntyre KM, Sasahara AA, Wenger NK, Willis PW (1975). "The electrocardiogram in acute pulmonary embolism". Prog Cardiovasc Dis. 17 (4): 247–57. PMID 123074.CS1 maint: Multiple names: authors list (link)
5. ↑ Kucher N, Walpoth N, Wustmann K, Noveanu M, Gertsch M (2003). "QR in V1--an ECG sign associated with right ventricular strain and adverse clinical outcome in pulmonary embolism". European Heart Journal. 24 (12): 1113–9. PMID 12804925. Retrieved 2011-12-05. Unknown parameter `|month=` ignored (help)CS1 maint: Multiple names: authors list (link)
6. ↑ Richman PB, Loutfi H, Lester SJ, Cambell P, Matthews J, Friese J; et al. (2004). "Electrocardiographic findings in Emergency Department patients with pulmonary embolism". J Emerg Med. 27 (2): 121–6. doi:10.1016/j.jemermed.2004.04.007. PMID 15261352.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
7. ↑ 7.0 7.1 Todd K, Simpson CS, Redfearn DP, Abdollah H, Baranchuk A (2009). "ECG for the diagnosis of pulmonary embolism when conventional imaging cannot be utilized: a case report and review of the literature". Indian Pacing Electrophysiol J. 9 (5): 268–75. PMC 2735159. PMID 19763195.CS1 maint: Multiple names: authors list (link) CS1 maint: PMC format (link)
8. ↑ Mohsen A, El-Kersh K (2013). "Variable ECG findings associated with pulmonary embolism". BMJ Case Rep. 2013. doi:10.1136/bcr-2013-008697. PMID 23449833.
9. ↑ Raghav KP, Makkuni P, Figueredo VM (2011). "A review of electrocardiography in pulmonary embolism: recognizing pulmonary embolus masquerading as ST-elevation myocardial infarction". Rev Cardiovasc Med. 12 (3): 157–63. PMID 22145193. `|access-date=` requires `|url=` (help)CS1 maint: Multiple names: authors list (link)
10. ↑ Goldhaber SZ (1998). "Pulmonary embolism". N Engl J Med. 339 (2): 93–104. doi:10.1056/NEJM199807093390207. PMID 9654541.
11. ↑ McGinn S, White PD. Acutecor pulmonale resulting from pulmonary embolism. J Am Med Assoc 1935;104:1473–1480.
12. ↑ Panos RJ, Barish RA, Whye DW, Groleau G (1988). "The electrocardiographic manifestations of pulmonary embolism". J Emerg Med. 6 (4): 301–7. PMID 3225435.CS1 maint: Multiple names: authors list (link)

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