engleski

Clinical and electrocardiography markers of right ventricle strain and early adverse outcome in patients with pulmonary embolism: results of single centre prospective study

Introduction: Right ventricular dysfunction (RVD) is central hemodynamic event in acute pulmonary embolism (PE), and represents independent prognostic factor of adverse event. Clinical signs of shock and hypotension in PE pts are most prominent signs of acute RVD associated with poor prognosis. In hemodynamically stable patients (with or without RVD) there is vast clinical variability where clinical signs and symptoms do not allow exclusion or confirmation of PE but increase the index of suspicion. Some ECG signs, indicated as right ventricular (RV) strain pattern (S1Q3T3 pattern, right bundle branch block (RBBB), and/or inverted T waves in V1-V4 leads) were shown to be related to RV pressure overload and dysfunction, as well as to the degree of pulmonary vascular obstruction. Some studies suggest that ECG derived RV strain pattern might be of a prognostic value in PE pts. The aim of present study was to evaluate prognostic value of clinical and ECG signs associated with early adverse outcome of PE pts. Methods: A prospective study was conducted at the Intensive Care Unit (ICU) in Sisters of Mercy University Hospital Center, Zagreb, Croatia, during 2010. The survey included all consecutive PE pts treated at the ICU. Main outcome measure was in-hospital death. The secondary outcome measure was the proportion of PE pts divided into three severity groups, PE clinical signs and ECG findings of RV strain. Dynamics of the ECG findings of interest were evaluated in pts in whom three consecutive ECGs were recorded. Good outcome was defined as the discharge from the hospital. Multivariate logistic regression analysis was performed to estimate factors independently associated with death. Goodness-of-fit statistics showed that the model fitted very well, multicollinearity was not present. Results: The study population included 104 ICU pts with confirmed diagnosis of PE. Mean age of the pts was 68.7±13.4 years with female predominance (63.5%). Pts were divided into three severity groups: high-risk (n=33 ; 31.7%), intermediate- (n=51 ; 49.1%) and low-risk (n=20 ; 19.2%). In analyzed co- morbidities and risk factors for PE there was significantly higher number of pts with high- risk PE in none-surgical pts (Fishers exact test, p=0.007). Although dyspnoea was present in 91.3% of PE pts as a leading symptom, there was significantly lower number of pts with dyspnoea in non-high-risk PE group (Fishers exact test, P=0.022). The duration of symptoms before admittance to the hospital was shorter in high- risk PE group (Fishers exact test, P=0.023). Higher respiratory rate was connected with high- and intermediate-risk PE (Fishers exact test, P=0.011), as well as the chest pain, tachycardia, hypotension, syncope, distended neck veins, and tricuspidal regurgitation (Fishers exact test, P=0.030 ; P=0.002 ; P<0.001 ; P<0.001 ; P=0.002 ; and p=0.030 respectively). Syncope, hypotension, protodyastolic gallop and distended neck veins were more frequently recorded in the PE non- survivors (Fishers exact test, P=0.045 ; P<0.001 ; P=0.009 ; P=0.016 respectively). Among ECG signs of PE most frequent were sinus tachycardia (48 pts, 46.1%), and S1Q3T3 pattern (58 pts, 55.8%), while RBBB occurred in 17 (16.4%) pts. Significantly higher number of pts with sinus tachycardia and RBBB were recorded in the high- and intermediate-risk PE groups (Fishers exact test, P<0.001 for both). During monitored 72- hours, in three consecutive ECGs there was significant decrease in occurrence of sinus tachycardia, and supraventricular tachyarrhythmias (Cohran-Mantel-Hanszel test, P<0.001 ; P=0.014 respectively) and increase in inverted T waves (P<0.001). Two factors were independently associated with death during the episode of PE: appearance of RBBB (OR 111.36, 95% CI 12.74- 973.21, p<0.001) and the presence of the distended neck veins (OR 15.36, 95%CI 1.81-130.51, p=0.012). Conclusion: Clinical signs and ECG changes representing RV strain might be useful in detection of pts with PE who are in increased risk of PE related complications and adverse outcome. Among these, according to our study, RBBB and distended neck veins were independent risk factors for in- hospital death.

acute pulmonary embolism ; clinical signs ; ECG ; outcome

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