Transient bundle branch block and other electrocardiographic changes in pulmonary embolism

Durant, Thomas M.; Ginsburg, Ilana; Roesler, Hugo

doi:10.1016/s0002-8703(39)90592-2

Cited by 56 publications

(8 citation statements)

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“…Simple clinical procedures such as history, physical ex amination and chest x-ray may help the physician to suspect this condition [25,26], ECG has been used with little success to diagnose pulmonary embolism [4,5,7,9]. Patterns as SiQyTy or RBBB, previously described as typical for pulmonary embo lism, do not occur frequently [6].…”

Section: Discussionmentioning

confidence: 99%

“…In addition to history, symp- toms, physical examination and chest xray, electrocardiography is a common procedure on which the suspicion of pul monary embolism may be raised. Never theless, since the original description of McGinn and White [4] in 1935, ECG pat terns suggestive of pulmonary embolism have never been controlled [5][6][7][8][9][10][11][12][13][14], The aim of this work was to assess the role of ECG in raising the suspicion of pulmonary embolism and in distinguish ing the patients who, subsequently, were shown to have pulmonary embolism from those in whom the suspicion was not con firmed. To this purpose, in a group of 374 consecutive patients with suspicion of pul monary embolism, we analyzed the ECG both at the time of diagnosis and during recovery.…”

Section: Introductionmentioning

confidence: 99%

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Routine Electrocardiography in Screening for Pulmonary Embolism

et al. 1986

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In a group of 245 patients with clinical suspicion of pulmonary embolism we analyzed the ECG for 22 signs that have been associated with this disease. Subsequently, the patients were divided into two groups: those with confirmed embolism and those in whom embolism was not confirmed. The occurrence of the ECG signs was assessed separately for the two groups. Furthermore, we related ECG features to severity of embolism as estimated at lung scan. Tachycardia and S-T depression were the commonest findings in both groups. P-R displacement, late R in aVR, S₁Q₃T₃, S slurred and T inversion in V₁-V₂ were more frequent in embolic than in nonembolic patients (p < 0.05 or less). All the abovementioned signs were more frequent at diagnosis than at recovery in embolic patients (p < 0.05 or less), whereas only tachycardia was more frequent at diagnosis than at control in nonembolic patients (p < 0.001). S-T depression and T inversion in V₁-V₂ were also associated to severity of embolism.Since some ECG signs are very frequent or specific in pulmonary embolism, this condition should always be suspected when they are found and, particularly, when previously absent in the same patients and/or not explained by other conditions

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Routine Electrocardiography in Screening for Pulmonary Embolism

et al. 1986

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“…The time intervals between the occurrence of the embolism and the taking of the electrocardiogram in our seven cases are as follows: Case 45, 1 hour; Cases 40 and 46, 12 hours; Cases 43 and 49, 24 hours; Case 42, 2 days; and Case 50, 22 days. Durant et al (1939) were of the opinion that right bundle-branch block changes were an early finding and a transient one, but Case 50 in our series showed right bundle-branch block to be present 22 days after the embolism.…”

Section: Durationmentioning

confidence: 49%

“…The remaining two patients were followed only for 16 and 18 days and no changes in the T wave took place during this time. Durant et al (1939) published an account of three cases in which right bundle-branch block was seen to be present during the first hour or two after the embolism and disappeared after about 12 hours. Wood (1948) found transient right bundlebranch block patterns in three of his twenty cases.…”

Section: Durationmentioning

confidence: 99%

The Electrocardiogram in Pulmonary Embolism

Cutforth¹,

Oram²

1958

Heart

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The importance of the electrocardiogram in the diagnosis of pulmonary embolism was first demonstrated by McGinn and White (1935) but general opinion still varies concerning the precise diagnostic value of this method of investigation. As recently as 1952 Newman stated that in only 10-20 per cent of cases of pulmonary embolism is there a characteristic pattern and that electro--cardiographic examination is not a good method of making the diagnosis. By contrast, Phillips and Levine (1950) are of the opinion that the diagnosis of pulmonary embolism can be made with a high degree of accuracy and, indeed, that the first clue to the diagnosis may often be found by this method.The object of this paper is to analyse in detail the electrocardiograms of 50 undoubted cases of pulmonary embolism and to compare these results with those of other workers in order to assess its value in making the diagnosis. In addition, an attempt is made to correlate the severity of the clinical picture with the electrocardiogram, and also to show how the presence or absence of pulmonary infarction affects it. MATERIAL AND METHOD OF SELECTIONThe material was obtained from the records of four hospitals. About a quarter of the cases were seen personally by one of us within 24 hours of the time at which the embolism occurred. All patients had at least one 12-lead electrocardiogram (the three standard leads, the three unipolar limb leads, and six chest leads, VI-6) taken after the embolism and in 25 instances serial records were obtained.In a study of this kind there are two practical difficulties in obtaining suitable material. The first is to obtain records from patients in whom there is no doubt whatsoever concerning the certainty of the diagnosis. This is discussed below and our diagnostic criteria are given. The second difficulty is that those patients who die very soon after the onset of the embolism frequently do so before there is time for an electrocardiogram to be taken. In this series of 50 patients there are 11 in whom the diagnosis was verified after death. The post-mortem examinations revealed that the coronary arteries were patent in all except Case 43, and this case is discussed separately.Details of the 11 cases that came to autopsy can be seen in Table I.In addition to the autopsied cases we studied 83 other patients in whom a clinical diagnosis of pulmonary embolism had been made but we discarded 44 of these because, in our opinion, the clinical picture was not certain enough to put the diagnosis beyond all doubt. The remaining 39 patients were considered by us to be undoubted examples of pulmonary embolism, our criteria being as follows.Twenty-one suffered a sudden attack of pleuritic pain followed in a few days by hrmoptysis. This attack occurred either within 14 days of a surgical operation or in the presence of a recent venous thrombosis. In none of them did we find any cause other than pulmonary embolism that could explain the clinical picture. In addition, every patient in this group had either 41 on 12 May 2018 by guest....

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“…7 ECG abnormalities, such as the S I Q III T III pattern, right bundle branch block, and anterior T wave inversion, have been observed to return to normal after treatment for PE. [8][9][10] Ferrari and colleagues 10 observed that anterior T wave inversion was present in 85% of cases of massive PE and 19% of cases of non-massive PE, and that its reversibility before the 60th day pointed to a good outcome. They also found that ECG findings of sinus tachycardia and pulmonary P wave as determined by amplitude of > 0.25 mV in lead II (both present in this case) each had 100% specificity and 100% positive predictive value in assessing the severity of PE but had poor sensitivity and negative predictive value.…”

Section: Discussionmentioning

confidence: 99%

Instructive ECG series in massive bilateral pulmonary embolism

Cheng

Money-Kyrle²

2005

Heart

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The ECG is abnormal in over 70% of patients with pulmonary embolism. Certain ECG abnormalities have been observed to return to normal after treatment. This case report describes an instructive ECG series in a patient with massive bilateral pulmonary embolism as shown by spiral computed tomography. The initial ECG showed sinus tachycardia with P pulmonale, although atrial tachycardia could not definitively be excluded. The patient had an increased troponin I concentration and echocardiographic evidence of right ventricular dysfunction and underwent thrombolysis with alteplase and anticoagulation with warfarin. P wave amplitude gradually decreased throughout admission and her tachycardia resolved. This may reflect a reduction in right atrial strain after treatment. This phenomenon has apparently not been described in this setting. The significance of ECG changes and the role of thrombolysis in pulmonary embolism are briefly discussed.A 61 year old retired nurse was referred by her general practitioner to the casualty department with breathlessness and central chest tightness, which was pleuritic and not associated with palpitations or autonomic symptoms. She had no cough or haemoptysis. For the preceding nine months she had also noted a swollen, tender left leg, in which she was known to have varicose veins. She took hormone replacement therapy (HRT) for post-menopausal symptoms. She had no other risk factors for venous thromboembolism or ischaemic heart disease. The patient was ambulant and independent with respect to activities of daily living. She was a non-smoker and only occasionally drank alcohol.On examination, her temperature was 37.8˚C. Heart rate was 140 beats/min, and blood pressure was 140/80 mm Hg. Jugular venous pressure was not reported to be increased. Heart sounds were normal. Arterial blood gases on air were within normal limits, with oxygen saturation of 99% on air. Her respiratory rate was 16 respirations/min. Her chest was clear to auscultation. There was bilateral pitting oedema, more so in the left leg, in which there was evidence of varicose veins. The left leg was not tender to palpation and was not erythematous. The chest radiograph and other examination were unremarkable.Blood results were as follows: haemoglobin 8.25 mmol/l, white cell count 3.6 6 10 9 /l, platelets 266 6 10 9 /l, C reactive protein 20.1 mg/l; sodium 134 mmol/l, potassium 4.2 mmol/ l, urea 4.9 mmol/l, creatinine 73 mmol/l; albumin 36 g/l, total protein 68 g/l, alkaline phosphatase 108 IU/l, bilirubin 3 mmol/l, alanine transaminase 113 IU/l; thyroid stimulating hormone 31 mIU/l; and free thyroxine 11.7 pmol/l.A screening echocardiogram showed a dilated hypokinetic right ventricle. A working diagnosis of pulmonary embolism (PE) was made. Subcutaneous enoxaparin and analgesia were administered, and antiembolic stockings were applied. HRT was stopped. The initial ECG showed a tachycardia with tall P waves and low voltage QRS complexes (fig 1). Since atrial tachycardia was considered in the differential diagnosis, adenosine ...

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Transient bundle branch block and other electrocardiographic changes in pulmonary embolism

Cited by 56 publications

References 3 publications

Routine Electrocardiography in Screening for Pulmonary Embolism

Routine Electrocardiography in Screening for Pulmonary Embolism

The Electrocardiogram in Pulmonary Embolism

Instructive ECG series in massive bilateral pulmonary embolism

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