Precordial T-Wave Inversion in Massive Pulmonary Embolism

Abstract & Commentary

Source: Ferrari E, et al. The ECG in pulmonary embolism: Predictive value of negative T-waves in precordial leads—80 case reports. Chest 1997;111:537-543.

Investigators in nice, france, analyzed records of 80 consecutive patients hospitalized in their special cardiology unit for acute pulmonary embolism (PE), focusing on the electrocardiograms (ECGs) obtained on admission and later during the hospitalization. All 80 patients underwent right heart catheterization and pulmonary angiography; massive PE was present in 74% of the patients and submassive PE in 26%. In these patients with proven major PE, T-wave inversion in the precordial leads was the most common ECG abnormality, being present in 68%. T-wave inversion correlated better with the severity of the PE than the other ECG findings that were evaluated. Among patients with anterior T-wave inversion, 90% had a Miller index over 50%, indicating massive PE, and 80% had a mean pulmonary arterial pressure greater than 30 mmHg. Disappearance of T-wave inversion before the sixth hospital day was associated with greater resolution of the emboli as measured by Miller index and mean pulmonary arterial pressure.

COMMENT BY DAVID J. PIERSON, MD

The classic ECG findings of "S1 Q3 T3" are familiar to physicians, as is the fact that this finding and other ECG abnormalities associated with PE do not occur often enough to be of much use in making the diagnosis. The incidence of the S1 Q3 T3 pattern has varied from about 10% to about 50% of cases in various clinical series; in the present study, in which an unusually large number of patients had massive PE, this pattern was found in 40 of 80 patients.

This study is of interest not because of what it says about the ECG in diagnosing PE but what it says about its value in assessing prognosis. If present, the anterior ischemic pattern of T-wave inversion goes along with massive PE and represents a greater potential threat of mortality than does the submassive PE. In addition, the failure of this pattern to resolve over the next several days suggests that a high, physiologically important degree of pulmonary arterial obstruction persists. (Dr. Pierson is Professor of Medicine at the University of Washington and Medical Director of Respiratory Care at Harborview Medical Center in Seattle.)