Rationale: Electrocardiographic (ECG) changes may occur during the acute phase of pulmonary embolism (PE). However, these changes are not specific for PE diagnosis and their prognostic role remains debatable. We aimed to investigate whether the ECG changes could predict shortterm prognosis of PE. Methods: We retrospectively reviewed 1,036 consecutive patients hospitalized at a tertiary referral center with a computed tomographic (CT) diagnosis of PE. The patients were classified into the adverse outcome (n = 120) and low-risk (n = 916) groups, and their clinical characteristics were compared. Results: An elevated N-terminal-pro-B-type natriuretic peptide (NT-proBNP, ≥1136 pg/mL) or troponin I blood level (≥0.05 ng/mL); ECG changes (T-wave inversion in V1-3, S1Q3T3, and right bundle branch block); high pulmonary embolism severity index (PESI, class III-V); and central PE or right ventricular dilatation on computed tomography (RVD-CT) significantly predicted an adverse outcome in multivariate analysis. The C-statistic of the ECG change was not significantly different from those of PESI, blood biomarker, central PE and RVD-CT. Compared to PESI alone, the addition of ECG changes, central PE, and RVD-CT to PESI significantly increased the C-statistic. Adding central PE, RVD-CT, or blood biomarker to the PESI/ECG changes further increased the C-statistic of the PESI/ECG changes. Conclusions: The ECG changes suggestive of RV strain may be an independent predictor of adverse outcomes in patients with acute PE. When ECG changes and subsequently central PE, RVD-CT, or blood biomarker are added to PESI, the prognostic performance shows a stepwise increase.
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