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Clinical Investigations: CARDIOLOGY |

Assessment of Cardiac Stress From Massive Pulmonary Embolism With 12-Lead ECG*

Kurt R. Daniel, DO; D. Mark Courtney, MD; Jeffrey A. Kline, MD
Author and Funding Information

Affiliations: *From the Oklahoma State University College of Osteopathic Medicine (Dr. Daniel), Tulsa, OK; and the Department of Emergency Medicine (Drs. Courtney and Kline), Carolinas Medical Center, Charlotte, NC. ,  Dr. Daniel is currently at the Bowman-Gray School of Medicine, Dept of Internal Medicine, Wake Forest University, Winston-Salem, NC.

Correspondence to: Jeffrey Kline, MD, Assistant Director of Research, Department of Emergency Medicine, Carolinas Medical Center, PO Box 32861, Charlotte, NC 28232; e-mail: Jkline@carolinas.org



Chest. 2001;120(2):474-481. doi:10.1378/chest.120.2.474
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Background: Massive pulmonary embolism (PE) that causes severe pulmonary hypertension can produce specific ECG abnormalities. We hypothesized that an ECG scoring system would vary in proportion to the severity of pulmonary hypertension and would help to distinguish patients with massive PE from patients with smaller PE and those without PE.

Methods: A 21-point ECG scoring system was derived (relative weights in parentheses): sinus tachycardia (2), incomplete right bundle branch block (2), complete right bundle branch block (3), T-wave inversion in leads V1 through V4 (0 to 12), S wave in lead I (0), Q wave in lead III (1), inverted T in lead III (1), and entire S1Q3T3 complex (2). ECGs obtained within 48 h prior to pulmonary arteriography were located for 60 patients (26 positive for PE, 34 negative for PE) and for 25 patients with fatal PE.

Results: Interobserver agreement (11 readers) for ECG score was good (Spearman r = 0.74). The ECG score showed significant positive relationship to systolic pulmonary arterial pressure (sPAP) in patients with PE (r = 0.387, p < 0.001), whereas no significant relationship was seen in patients without PE (r = − 0.08, p = 0.122). When patients were grouped by severity of pulmonary hypertension (low, moderate, severe), only patients with severe pulmonary hypertension from PE had a significantly higher ECG score (mean, 5.8 ± 4.9). At a cutoff of 10 points, the ECG score was 23.5% (95% confidence interval [CI], 16 to 31%) sensitive and 97.7% (95% CI, 96 to 99%) specific for the recognition of severe pulmonary hypertension (sPAP > 50 mm Hg) secondary to PE. In 25 patients with fatal PE, the ECG score was 9.5 ± 5.2.

Conclusions: The derived ECG score increases with severity of pulmonary hypertension from PE, and a score≥ 10 is highly suggestive of severe pulmonary hypertension from PE.

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