Changing electrocardiographic findings in pulmonary embolism in relation to vascular obstruction

Electrocardiographic (ECG) findings in 87 consecutive patients with from minor to massive pulmonary embolism are presented. ECG changes suggestive of acute right ventricular strain defined as the occurrence of complete (c) or incomplete (inc) right bundle branch block (RBBB), an SIQIIITIII pattern, inverted T waves in the second and third precordial leads and/or an increase in the frontal QRS axis of 20 degrees C or more were found in 71 patients (82%). The prevalence of c and inc RBBB and the increase in frontal QRS axis correlated with the extent of embolization (angiographic or scintigraphic score), while the appearance of the SIQIIITIII pattern did not. No patient with a vascular obstruction of two thirds or more had an ECG free of signs of right ventricular strain. In 9 of 11 embolectomized patients with c RBBB, c RBBB disappeared within 24 h postoperatively. Among patients with an embolization of 45% or more, those with c RBBB had a shorter symptom duration, fewer embolic episodes and a lower pulmonary artery pressure than those without c RBBB. As ECG abnormalities were transient and changing in nature, serial ECG recordings are recommended. Pronounced ECG signs of right ventricular strain should, as they may reflect both massive and short-lasting vascular obstruction, arouse the suspicion of pulmonary embolism suitable for embolectomy.