Prognostic value of ECG among patients with acute pulmonary embolism and normal blood pressure

Am J Med. 2009 Mar;122(3):257-64. doi: 10.1016/j.amjmed.2008.08.031.


Objective: To investigate the prognostic value of electrocardiography (ECG) alone or in combination with echocardiography in patients with acute pulmonary embolism and normal blood pressure.

Methods: Consecutive adult patients presenting to the emergency department at Azienda Ospedaliero-Universitaria Careggi with the first episode of pulmonary embolism were included. Patients with systolic blood pressure less than 100 mm Hg were excluded. ECG and echocardiography were performed within 1 hour from diagnosis and evaluated in a blinded fashion. Right ventricular strain was diagnosed in the presence of one or more of the following ECG findings: complete or incomplete right ventricular branch block, S1Q3T3, and negative T wave in V1-V4. The main outcome measurement was clinical deterioration or death during in-hospital stay. The association of variables with the main outcome was evaluated by multivariate Cox survival analysis.

Results: A total of 386 patients with proved pulmonary embolism were included in the study; 201 patients (52%) had right ventricular dysfunction according to echocardiography, and 130 patients (34%) showed right ventricular strain. Twenty-three patients (6%) had clinical deterioration or died. At multivariate survival analysis, right ventricular strain was associated with adverse outcome (hazard ratio 2.58; 95% confidence interval, 1.05-6.36) independently of echocardiographic findings. Patients with both right ventricular strain and right ventricular dysfunction (26%) showed an 8-fold elevated risk of adverse outcome (hazard ratio 8.47; 95% confidence interval, 2.43-29.47).

Conclusion: Right ventricular strain pattern on ECG is associated with adverse short-term outcome and adds incremental prognostic value to echocardiographic evidence of right ventricular dysfunction in patients with acute pulmonary embolism and normal blood pressure.

Publication types

  • Clinical Trial

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Aged, 80 and over
  • Blood Pressure / physiology
  • Echocardiography / methods
  • Electrocardiography / methods*
  • Female
  • Fibrinolytic Agents / administration & dosage
  • Heparin / administration & dosage
  • Humans
  • Male
  • Middle Aged
  • Myocardium / chemistry
  • Prognosis
  • Pulmonary Embolism / diagnosis*
  • Pulmonary Embolism / diagnostic imaging
  • Pulmonary Embolism / drug therapy
  • Pulmonary Embolism / physiopathology*
  • Troponin I / analysis
  • Ventricular Dysfunction, Right / diagnostic imaging
  • Ventricular Dysfunction, Right / physiopathology
  • Young Adult


  • Fibrinolytic Agents
  • Troponin I
  • Heparin