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Table of Contents
LETTERS TO THE EDITOR  
Year : 2020  |  Volume : 23  |  Issue : 4  |  Page : 543
Is ECG an aid to differentiate pulmonary embolism from ACS?


1 Department of Emergency and Critical Care, Manian Medical Centre, Erode, Tamil Nadu, India
2 Department of Emergency Medicine, Hamad Medical Corporation, Doha, Qatar
3 Department of Cardiology, Epsom and St Helier University, NHS Trust, London, UK
4 Department of Emergency Medicine, DM Wayanad Institute of Medical Sciences, Kerala, India
5 Department of Internal Medicine, Trichy SRM Medical College Hospital and Research Center, Irungalur, Trichy, Tamil Nadu, India

Click here for correspondence address and email

Date of Submission26-Feb-2019
Date of Acceptance05-May-2019
Date of Web Publication19-Oct-2020
 

How to cite this article:
Senthilkumaran S, Karthikeyan N, Meenakshisundaram R, Florence B, Thirumalaikolundusubramanian P. Is ECG an aid to differentiate pulmonary embolism from ACS?. Ann Card Anaesth 2020;23:543

How to cite this URL:
Senthilkumaran S, Karthikeyan N, Meenakshisundaram R, Florence B, Thirumalaikolundusubramanian P. Is ECG an aid to differentiate pulmonary embolism from ACS?. Ann Card Anaesth [serial online] 2020 [cited 2020 Nov 24];23:543. Available from: https://www.annals.in/text.asp?2020/23/4/543/298537




To the Editor,

We read the article by Ambesh et al.[1] which highlights electrocardiographic constraints/limitations to distinguish pulmonary embolism (PE) from acute coronary syndrome (ACS) in emergencies. We would like to mention the usefulness of negative T waves in the inferior and precordial leads, as well as ST-segment deviation (STDV) (elevation and/or depression) in the differentiation of PE from ACS with the help of bedside ECG.

Negative T waves in the inferior and precordial leads are often recognized in patients with acute coronary syndromes (ACS). However, one should remember and look for the appearance of negative T waves in patients with acute pulmonary embolism (PE) which have been suggested as a marker of right ventricular strain or right ventricular dysfunction.[2] Kosuge et al.[2] compared ECGs of patients with ACS and PE, and reported that an RV strain pattern with negative T waves in leads III and V1 in combination with negative T waves in precordial leads were seen in only 1% of patients with ACS when compared with 88% of acute PE with a sensitivity of 88% and specificity of 97%. These ECG abnormalities contribute to significant component of the 21- point ECG score by Daniel et al.[3] with up to 15 points being assigned based on the presence and depth of negative T wave in leads V1-V3. In short, negative T waves in leads III, V1 and V2 are common in patients with PE.

ST-segment deviation (STDV) (elevation and/or depression) is another common ECG manifestation of PE, even though ST-segment depression (STD) is not included in Daniel's 21- point ECG score. However, several studies have described potential prognostic value associated with this STDV in the setting of acute PE rather than chronic PE.[4]

Ischemic ECG patterns, though commonly seen in PE invariably cause emergency physicians and practitioners to often diagnose ACS and then proceed to handle the case as per protocol.[5] Hence, it is suggested to consider acute PE based on the negative T waves in the inferior and precordial leads, and to avoid over diagnosis leading to unwanted medical investigations and treatment even in resource limited environment. Hence, the emergency physicians and practitioners—while facing clinical challenges of ACS—have to read and interpret ECG with the keen idea of excluding or differentiating ACS from PE and decide accordingly from the point of patient safety and quality of care. In other words, the more we think pf PE, the more we are likely to diagnose these cases and provide them with appropriate care.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Ambesh P, Kapoor A, Kumar S, Jain SK. The dilemma of the “ischemic-looking” electrocardiogram: Pulmonary embolism or acute coronary syndrome? Ann Card Anaesth 2019;22:89-91.  Back to cited text no. 1
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2.
Kosuge M, Ebina T, Hibi K, Tsukahara K, Iwahashi N, Gohbara M, et al. Differences in negative T waves among acute coronary syndrome, acute pulmonary embolism, and Takotsubo cardiomyopathy. Eur Heart J 2012;1:349-57.  Back to cited text no. 2
    
3.
Daniel KR, Courtney DM, Kline JA. Assessment of cardiac stress from massive pulmonary embolism with 12-lead electrocardiography. Chest 2001;120:474-81.  Back to cited text no. 3
    
4.
Zhan ZQ, Wang CQ, Wang ZX, Nikus KC, Baranchuk A, Yuan RX, et al. Significance of ST-segment deviation in patients with acute pulmonary embolism and negative T waves. Cardiol J 2015;22:583-9.  Back to cited text no. 4
    
5.
Senthilkumaran S, Jena NN, Balamurugan N, Benita F, Thirumalaikolundusubramanian P. The electrocardiogram in pulmonary embolus: Diagnostic applications. Am J Emerg Med 2019;37:165-6.  Back to cited text no. 5
    

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Correspondence Address:
Subramanian Senthilkumaran
Department of Emergency and Critical Care, Manian Medical Centre, 100, Power House Road, Erode, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aca.ACA_39_19

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