Lit Matters 1: Can the ECG help us reliably pick up RV dysfunction in PE patients?

Pulmonary embolism can produce ECG signs of right-heart strain, but most findings are better at flagging RV dysfunction than predicting who will crash. In acute PE, supraventricular tachycardia stands out as the ECG finding most associated with early clinical deterioration, while a normal ECG lowers that risk.

ECG Risk Stratification in PE

• SVT as danger signal: Supraventricular tachycardia was the standout red flag for 5-day clinical deterioration in acute PE, with an odds ratio near 2.9 and clear bedside implications when the patient otherwise looks borderline.
• Normal ECG reassurance: Absence of ECG abnormalities was associated with lower short-term deterioration risk, making a completely unremarkable tracing modestly reassuring rather than simply nondiagnostic.
• RV strain patterns: Precordial T-wave inversion, incomplete RBBB, S1Q3T3, sinus tachycardia, and ST elevation in aVR all tracked with abnormal right ventricular findings on echo.
• Echo still matters: Goal-directed echocardiography remained the stronger marker of impending trouble, with abnormal RV findings carrying an odds ratio above 4 for early deterioration. We get into the bedside role of ECG versus echo in the episode.
• Pattern burden signal: About 65% of patients had at least one abnormal ECG finding, and the total number of strain patterns helped identify patients less likely to be low risk by standard PE tools.
• Bedside takeaway: Use an abnormal ECG in confirmed PE as a risk-stratification prompt, especially when you see SVT or clustered RV-strain findings, while remembering chronic baseline abnormalities can muddy the picture.