P394ECG and echocardiographic changes of right heart strain, biomarkers and outcomes following acute pulmonary embolism

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Indicators of right ventricular (RV) dysfunction on ECG, echocardiogram (Echo) and raised biomarkers have independently been associated with an increased risk of mortality in acute pulmonary embolism (PE). Risk stratification is recommended by ESC. We assessed if detailed assessment of changes in ECG, Echo and biomarkers could predict PE and outcome.Method: Retrospective analysis of all patients with acute PE admitted to to the hospital over 1 year. Mortality, length of stay (LOS), co-morbidities and a biomarker cardiac Troponin I (TnI) were recorded (elevated >0.07). ECG and Echo were analysed looking for changes of right heart strain.Results: 124 patients (51% male, aged 25-95) had PE confirmed by CT pulmonary angiogram (75%), CT chest (12%) and perfusion scan (11%). ECG was performed in 93%, TnI in 48% and Echo in 51%. TnI was higher in those that died compared to survivors, 3.84 vs 0.38 (p=0.43). Most were in sinus rhythm (56%), sinus tachycardia (25%) and AF (19%) with anterior T wave inversion (ATWI) (14%), RBBB (13%), RAD (8%) and S1Q3T3 (10%). TnI was notably higher in those with ATWI vs normal ECG (p=0.05). Pulmonary artery systolic pressure (PASP) was higher in those with AF (45.9+/-4.7mmHg) and ATWI (49.5+/-18.6) vs those with normal ECG (35.6+/-13.0), though none were significant. LOS was longer in those with AF (17.7+/-9.7 days) and ATWI (17.4+/-17.8) vs normal ECG (9.2+/-6.6). Mortality was higher at one and 12 months in those with AF (18 and 41% respectively) and RBBB (13 and 25%) vs normal (2 and 10%). On Echo, mean PASP was raised (36.9mmHg +/-15.2), right ventricular (RV) basal diameter was moderate-severely dilated (3.46cm+/-0.89), the mid ventricular wall mildly dilated (2.92+/-0.65), RV length remained normal (7.14+/-1.12) and RV outflow tract mildly dilated (3.04+/-0.52). As PASP increased, the basal RV dimension increased significantly (correlation co-efficient 0.65). No echo parameter could predict length of stay.Conclusion: TnI was higher in those that died, but not significant. ECG changes of ATWI predicted a significantly higher TnI rise vs normal ECG. Mortality was higher at one and 12 months in those with AF or RBBB, but may be related to co-morbidities. Basal RV rather than other RV dimensions increased significantly in acute PE and rose proportionately with rising PASP. This disproportionately dilated basal RV may compliment McConnell's sign (free wall hypokinesia with preserved apical function) when diagnosing PE. Multivariate analysis was not able to predict mortality or LOS with statistical significance.

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