Prognostic role of serial electrocardiographic changes in patients with acute pulmonary embolism. Data from the Italian Pulmonary Embolism Registry

Background: The prognostic role of serial electrocardiographic modifications in patients with acute pulmonary embolism (PE) have been poorly investigated. We evaluate the electrocardiographic changes in PE patients during their hospitalization and the prognostic role of such ECG modifications in respect to 30-day mortality in patients enrolled in the Italian Pulmonary Embolism Registry (IPER).Methods: Subjects enrolled into the IPER (September 2006-August 2010) were stratified according to their hemodynamic status, as high- (hemodynamically unstable) and non-high-risk (hemodynamically stable) patients. ECG features were analysed at three fixed time points: at presentation, on day 3 and at discharge.Results: Overall, 687 patients (286 males, mean age 69.0 +/- 15.5 years) were included in the study. Among these, 71 (10.3 %) were at high-risk. In these patients, multivariate analysis revealed that the persistence of right ventricular strain (RVS) after three days from hospitalization was a predictor of 30-day mortality [HRa: 2.78 (95 % CI: 1.05-7.31, p = 0.003)]. Moreover, the persistence of right bundle branch block (RBBB) [HRa: 2. 48 (95 % CI: 1.03-5.09, p = 0.002)], negative T waves in V1-V4 (NTWs) [HRa: 1.63 (95 % CI: 1.04-2.55), p < 0.0001] and qR complex in lead V1 [HRa: HR: 5.44, (95 % CI: 3.22-9.44, p < 0.0001)] were associated with an increased risk of 30-day mortality. When RBBB, NTWs and qR complex in V1 lead were present concomitantly, the 30-day risk of death resulted significantly higher [HR: 12.5 (95 % CI: 3.39-46.4,) p < 0.0001].Conclusions: Persistence of RBBB, NTWs, and qR pattern in V1 lead at day 3 of hospitalization are independent prognostic factors of death within 30 days in high-risk acute PE patients. The prognostic power of any single ECG abnormality is lower compared to the combination of the three ECG variables.