使用标准心电图对肺栓塞患者进行风险评估是否可行？

Is it possible to use standard electrocardiography for risk assessment of patients with pulmonary embolism?

作者信息

Kostrubiec Maciej, Hrynkiewicz Anna, Pedowska-Włoszek Justyna, Pacho Szymon, Ciurzyński Michał, Jankowski Krzysztof, Koczaj-Bremer Magdalena, Wojciechowski Artur, Pruszczyk Piotr

机构信息

Department of Internal Medicine and Cardiology, Medical University, Warsaw, Poland.

出版信息

Kardiol Pol. 2009 Jul;67(7):744-50.

PMID:19649996

Abstract

BACKGROUND

Risk stratification of patients with acute pulmonary embolism (APE) is crucial for appropriate treatment selection. Shock and hypotonia are known indications for aggressive management. However, in the haemodynamically stable group the best prognosis strategy is still being sought. Acute pulmonary embolism often provokes changes in electrocardiography recordings (ECG).

AIM

To assess whether ECG features recorded on admission can be useful for risk stratification during hospitalisation.

METHODS

We analysed 12-lead ECG and echocardiography of 56 patients (22 males, age: 64.3 +/- 17.9 years) with diagnosed APE. The diagnosis of APE was confirmed by spiral computer tomography. The ECG analysis was based on the 21-point ECG score including: the presence of tachycardia (> 100 beats/min), right bundle branch block, negative S waves in lead I, negative Q or T waves in lead III, S1Q3T3 complex and depth of negative T waves in leads V1-V4. ECG features were scored from 0 to 21 points. Complicated in-hospital course was defined as need for vasopressor, thrombolysis, embolectomy or resuscitation and the presence of shock index > 1 (heart rate/systolic blood pressure).

RESULTS

Four (7.1%) patients died during hospitalisation and in 8 (14.3%) others complications occurred. Patients with complications had higher mean sum of 21-ECG score compared to subjects with uneventful course [8 (1-17) vs. 3 (0-18); p = 0.04]. Right ventricular contractility dysfunction (RVD) in echocardiography was found in 13 (23.2%) patients, who had higher ECG score compared to patients without RVD [8 (3-17) vs. 2 (0-18); p = 0.004]. The area under the ROC curve to assess the usefulness of 21-ECG score to predict RVD was 0.794 (95% CI 0.665-0.891) and for PPH 0.727 (95% CI 0.591-0.837). The sensitivity and specificity, positive and negative predictive value for the value > 3 points in 21-ECG score to predict RVD were: 92, 65, 44, 97% and for PPH: 75, 46, 19, 92%, respectively.

CONCLUSIONS

21-ECG score is a simple and cheap method which can be used to predict RVD and serious complications in patients with APE. A value Ł 3 points in the 21-ECG score can exclude RVD with high probability and limit the need of echocardiography to 23% of haemodynamically stable patients.

摘要

背景

急性肺栓塞（APE）患者的风险分层对于选择合适的治疗方法至关重要。休克和低血压是积极治疗的已知指征。然而，在血流动力学稳定的患者组中，仍在寻找最佳的预后策略。急性肺栓塞常引起心电图记录（ECG）的变化。

目的

评估入院时记录的心电图特征是否有助于住院期间的风险分层。

方法

我们分析了56例确诊为APE的患者（22例男性，年龄：64.3±17.9岁）的12导联心电图和超声心动图。APE的诊断通过螺旋计算机断层扫描得以证实。心电图分析基于21分的心电图评分，包括：心动过速（>100次/分钟）、右束支传导阻滞、I导联S波阴性、III导联Q或T波阴性、S1Q3T3复合波以及V1-V4导联T波负向深度。心电图特征的评分范围为0至21分。住院期间的复杂病程定义为需要血管加压药、溶栓、栓子切除术或复苏以及休克指数>1（心率/收缩压）。

结果

4例（7.1%）患者在住院期间死亡，8例（14.3%）出现其他并发症。与病程平稳的患者相比，出现并发症的患者21项心电图评分的平均总和更高[8（1-17）对3（0-18）；p=0.04]。13例（23.2%）患者在超声心动图中发现右心室收缩功能障碍（RVD），与无RVD的患者相比，他们的心电图评分更高[8（3-17）对2（0-18）；p=0.004]。评估21项心电图评分预测RVD有效性的ROC曲线下面积为0.794（95%CI 0.665-0.891），预测PPH的为0.727（95%CI 0.591-0.837）。21项心电图评分>3分预测RVD的敏感性、特异性、阳性和阴性预测值分别为：92%、65%、44%、97%，预测PPH的分别为：75%、46%、19%、92%。