ECG For The Diagnosis Of Pulmonary Embolism When Conventional Imaging Cannot Be Utilized: A Case Report And Review Of The Literature

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Abstract

The diagnosis of acute pulmonary embolism has always been challenging. However, it has recently been greatly assisted through advances in radiological imaging. While imaging techniques are widely available, they cannot always be utilized. We report a case of acute pulmonary embolism in a patient with several prior pulmonary resections that would likely result in a non-diagnostic V/Q scan and acute renal insufficiency that was a relative contraindication to CT pulmonary angiography. The patient's electrocardiogram displayed several features suggestive of acute pulmonary embolism, which in the absence of effective radiological imaging, were essential in her diagnosis and management.

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Most cited references 26

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Multidetector computed tomography for acute pulmonary embolism.

Paul Stein, Sarah E. Fowler, Lawrence Goodman … (2006)

The accuracy of multidetector computed tomographic angiography (CTA) for the diagnosis of acute pulmonary embolism has not been determined conclusively. The Prospective Investigation of Pulmonary Embolism Diagnosis II trial was a prospective, multicenter investigation of the accuracy of multidetector CTA alone and combined with venous-phase imaging (CTA-CTV) for the diagnosis of acute pulmonary embolism. We used a composite reference test to confirm or rule out the diagnosis of pulmonary embolism. Among 824 patients with a reference diagnosis and a completed CT study, CTA was inconclusive in 51 because of poor image quality. Excluding such inconclusive studies, the sensitivity of CTA was 83 percent and the specificity was 96 percent. Positive predictive values were 96 percent with a concordantly high or low probability on clinical assessment, 92 percent with an intermediate probability on clinical assessment, and nondiagnostic if clinical probability was discordant. CTA-CTV was inconclusive in 87 of 824 patients because the image quality of either CTA or CTV was poor. The sensitivity of CTA-CTV for pulmonary embolism was 90 percent, and specificity was 95 percent. CTA-CTV was also nondiagnostic with a discordant clinical probability. In patients with suspected pulmonary embolism, multidetector CTA-CTV has a higher diagnostic sensitivity than does CTA alone, with similar specificity. The predictive value of either CTA or CTA-CTV is high with a concordant clinical assessment, but additional testing is necessary when the clinical probability is inconsistent with the imaging results. Copyright 2006 Massachusetts Medical Society.

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Major pulmonary embolism: review of a pathophysiologic approach to the golden hour of hemodynamically significant pulmonary embolism.

Susan K. Wood (2002)

Major pulmonary embolism (PE) results whenever the combination of embolism size and underlying cardiopulmonary status interact to produce hemodynamic instability. Physical findings and standard data crudely estimate the severity of the embolic event in patients without prior cardiopulmonary disease (CPD) but are unreliable indicators in patients with prior CPD. In either case, the presence of shock defines a threefold to sevenfold increase in mortality, with a majority of deaths occurring within 1 h of presentation. A rapid integration of historical information and physical findings with readily available laboratory data and a structured physiologic approach to diagnosis and resuscitation are necessary for optimal therapeutics in this "golden hour." Echocardiography is ideal because it is transportable, and is capable of differentiating shock states and recognizing the characteristic features of PE. Spiral CT scanning is evolving to replace angiography as a confirmatory study in this population. Thrombolytic therapy is acknowledged as the treatment of choice, with embolectomy reserved for those in whom thrombolysis is contraindicated.

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Clinical, laboratory, roentgenographic, and electrocardiographic findings in patients with acute pulmonary embolism and no pre-existing cardiac or pulmonary disease.

P D Stein, M L Terrin, C. Hales … (1991)

The history, physical examination, chest radiograph, electrocardiogram and blood gases were evaluated in patients with suspected acute pulmonary embolism (PE) and no history or evidence of pre-existing cardiac or pulmonary disease. The investigation focused upon patients with no previous cardiac or pulmonary disease in order to evaluate the clinical characteristics that were due only to PE. Acute PE was present in 117 patients and PE was excluded in 248 patients. Among the patients with PE, dyspnea or tachypnea (greater than or equal to 20/min) was present in 105 of 117 (90 percent). Dyspnea, hemoptysis, or pleuritic pain was present in 107 of 117 (91 percent). The partial pressure of oxygen in arterial blood on room air was less than 80 mm Hg in 65 of 88 (74 percent). The alveolar-arterial oxygen gradient was greater than 20 mm Hg in 76 of 88 (86 percent). The chest radiograph was abnormal in 98 of 117 (84 percent). Atelectasis and/or pulmonary parenchymal abnormalities were most common, 79 of 117 (68 percent). Nonspecific ST segment or T wave change was the most common electrocardiographic abnormality, in 44 of 89 (49 percent). Dyspnea, tachypnea, or signs of deep venous thrombosis was present in 107 of 117 (91 percent). Dyspnea or tachypnea or pleuritic pain was present in 113 of 117 (97 percent). Dyspnea or tachypnea or pleuritic pain was present in 113 of 117 (97 percent). Dyspnea or tachypnea or pleuritic pain or atelectasis or a parenchymal abnormality on the chest radiograph was present in 115 of 117 (98 percent). In conclusion, among the patients with pulmonary embolism that were identified, only a small percentage did not have these important manifestations or combinations of manifestations. Clinical evaluation, though nonspecific, is of considerable value in the selection of patients in whom there is a need for further diagnostic studies.

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Author and article information

Journal

Journal ID (nlm-ta): Indian Pacing Electrophysiol J

Journal ID (publisher-id): Indian Pacing Electrophysiol J

Title: Indian Pacing and Electrophysiology Journal

Publisher: Indian Heart Rhythm Society

ISSN (Electronic): 0972-6292

Publication date Collection: Sep-Oct 2009

Publication date (Electronic): 01 September 2009

Volume: 9

Issue: 5

Pages: 268-275

Affiliations

Division of Cardiology, Department of Medicine, Kingston General Hospital, Queen's University, Kingston, Ontario, Canada

Author notes

Address for correspondence: Dr Adrian Baranchuk, MD FACC, Assistant Professor of Medicine, Cardiac Electrophysiology and Pacing, Kingston General Hospital K7L 2V7, Queen's University. E-mail: barancha@ 123456kgh.kari.net

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Publisher ID: ipej090268-00

PMC ID: 2735159

PubMed ID: 19763195

SO-VID: c4f41b96-9a4f-4757-9518-2d991f8c839b

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This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ECG For The Diagnosis Of Pulmonary Embolism When Conventional Imaging Cannot Be Utilized: A Case Report And Review Of The Literature

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Most cited references 26

Multidetector computed tomography for acute pulmonary embolism.

Major pulmonary embolism: review of a pathophysiologic approach to the golden hour of hemodynamically significant pulmonary embolism.

Clinical, laboratory, roentgenographic, and electrocardiographic findings in patients with acute pulmonary embolism and no pre-existing cardiac or pulmonary disease.

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