Use of ischemic ECG patterns for risk stratification in intermediate-risk patients with acute PE.

BACKGROUND: European recommendations on the management of acute pulmonary embolism (APE) divide patients into 3 risk categories: high, intermediate, and low. Mortality has previously been estimated at 3% to 15% in the intermediate group. The aim of this study was to use a new metric "ischemic electrocardiographic (ECG) patterns" to more precisely estimate the risk (complications or death) of APE patients identified as "intermediate risk" by current European Society of Cardiology (ESC) criteria.

METHODS: The study group consisted of 500 consecutive patients (290 females), with a mean age 66.3 ± 15.2 years, and 245 (72.8%) patients were initially classified as intermediate risk. Four ischemic ECG patterns were studied: (i) ST-segment ischemic pattern (STIP), (ii) global ischemic pattern (GIP), (iii) negative T wave pattern, and (iv) control group consisting of patients with no ischemic changes.

RESULTS: Predictors of death in univariate analysis included elevated troponin concentration (odds ratio [OR], 6.8; 95% confidence interval [CI], 1.28-169; P = 0.02]) and ischemic ECG patterns: STIP (OR, 6.3; 95% CI, 1.6-46.0; P = 0.007). Patients with right ventricular dysfunction (RVD) who were STIP (+) experienced significantly higher mortality rate compared to RVD patients who were STIP(-) (11.4% vs 1.6%; OR, 7.26; 95% CI, 1.82-52.8; P = 0.004). In patients with STIP (+) as compared to STIP (-), rate of death (OR, 6.35; P = 0.007) and rate of complications (OR, 4.19; P = 0.002) were significantly higher. Neither presence of negative T-waves nor GIP pattern was associated with a worse prognosis.

CONCLUSIONS: In patients with APE, an ischemic ECG pattern on hospital admission, when identified in addition to classic risk markers, is an independent risk factor for worse in-hospital outcomes.