1. INTERNATIOINAL ACADEMYINTERNATIOINAL ACADEMY
OF CARDIOLOGYOF CARDIOLOGY
ANNUAL SCIENTIFIC SESSIONS 2015ANNUAL SCIENTIFIC SESSIONS 2015
2020THTH
WORLD CONGRESSWORLD CONGRESS
ON HEART DISEASEON HEART DISEASE
VANCOUVER, BC, CANADAVANCOUVER, BC, CANADA
JULY 25-27, 2015JULY 25-27, 2015
2. RESOLUTION OF THE S WAVE INRESOLUTION OF THE S WAVE IN
LEAD I: A CRITERION OFLEAD I: A CRITERION OF
SUCCESSFUL THROMBOLYSIS INSUCCESSFUL THROMBOLYSIS IN
ACUTE PULMONARY EMBOLISMACUTE PULMONARY EMBOLISM
Daniel B. Petrov, MDDaniel B. Petrov, MD
Maria H. Milanova. MD, PhDMaria H. Milanova. MD, PhD
Emergency Hospital “Pirogov”, Sofia, BulgariaEmergency Hospital “Pirogov”, Sofia, Bulgaria
3. ObjectiveObjective
To determine whether a simple,
readily applicable
electrocardiographic criterion
such as the rapid reduction of therapid reduction of the
S wave in lead IS wave in lead I (SISI), will allow
early prediction of successful
thrombolysis in patients with
acute massive pulmonary
embolism (PE).
4. ObjectiveObjective
Our aim was to study the
resolution of the S wave inS wave in
lead Ilead I as a marker and a simple
bedside tool for the prediction
of successful reperfusion after
fibrinolysis in acute PE.
5. BackgroundBackground
The main goal of thrombolytic
therapy in PE is to rapidly reverse
haemodynamic compromise and gas-
exchange derangements. Lack of
response to fibrinolysis within the
first 24 hours was prospectively
defined as both persistent clinical
instability and residual
echocardiographic right ventricularright ventricular
(RV) dysfunction.
6. BackgroundBackground
In myocardial infarction, ST segment
resolution 90-180 minutes after
thrombolysis is a strong predictor of
survival and preservation of left
ventricular function. It is a useful marker
of successful fibrinolysis and relates to
clinical outcome.
In contrast to myocardial infarction, there
is no strict ECG criteria for the
assessment efficacy of thrombolysis in
acute PE.
7. BackgroundBackground
We proposed a new electrocardiographic
sign for noninvasive assessment the
efficacy of thrombolytic therapy in acute
PE.We feel that the reduction of the S
wave in lead I would be a useful ECG
marker of successful fibrinolysis in
pulmonary embolism.
8. Material and MethodsMaterial and Methods
Our study enrolled two hundred
patients admitted in our Department
with the diagnosis of massive PE
during a period of thirteen years (from
the July 2001 to May 2014). The
diagnosis was initially set by clinical
symptoms, ECG abnormalities,
laboratory findings (D-dimer) and
confirmed by spiral computed
tomography scan (CT).
9. Material and MethodsMaterial and Methods
The severity of embolism was evaluated on
the basis of the extent to which the branch
of the pulmonary tree was affected (given
by the CT) and the degree of
haemodynamic consequences (evaluated
clinically and with echocardiography).
Thrombolysis involved the use of alteplase
at a dose 100 mg over a 2-hour period
followed by unfractioned heparin as a
bridge to anticoagulation with warfarin.
10. Material and MethodsMaterial and Methods
A baseline (pre-thrombolysis) 12-lead
ECG was recorded just before
initiation of alteplase and at 60, 120
minutes and 24 hour thereafter (post-
thrombolysis ECG). The ECGs were
recorded at standard gain (10 mV/mm)
and speed (25 mm/s).
11. Material and MethodsMaterial and Methods
The ECG marker studied was the
S wave in lead I >1 mm.
Patients with either
contraindications to fibrinolysisi
or previously intraventricular
conduction defects were excluded
from the study.
12. ResultsResults
On the basis of clinical and
echocardiographic criteria for
successful/unsuccessful thrombolysis
these 200 patients were divided into
two groups:
a successful thrombolysis group
with 136 (68%) patients (group Agroup A)
and
an unsuccessful group with 64
(32%) patients (group Bgroup B).
13. ResultsResults
We observed a newly emerged
deep S wave in lead I in 114
(84%) of the patients in group Agroup A
and a SI was present in 51 (80%)
of the subjects in group Bgroup B.
A rapid reduction of the SI in the
post-thrombolysis ECGs in the
first 24 hours was detected in 102
(90%) of the patients in group Agroup A.
14. ResultsResults
An echocardiogram taken on the next day
of the treatment showed normalization of
the RV systolic function and dimension
with a significant decrease in tricuspid
regurgitation and an estimated systolic
pulmonary artery pressure. There was no
resolution of the S wave in lead I in any
of the patients in group Bgroup B after
completion of fibrinolysis in the first 24
hours.
15. ConclusionsConclusions
It is possible that the S wave in lead I is
an indicator of major pulmonary artery
block.This is shown by the early
reduction of the S wave following
successful fibrinolysis.
In addition, the disappearance of a new
onset S wave can be used like ST
segment resolution in myocardial
infarction to assess efficacy of
fibrinolysis in acute PE.
16. ConclusionsConclusions
Finally, resolution of the S wave inS wave in
lead Ilead I can be used as an ECG
marker and a simple, non-costly,
bedside tool for predicting of
successful reperfusion after
thrombolysis in acute pulmonary
embolism.
17. Case ReportsCase Reports
Case 1
A 65-year-old man with a history of recent
hospitalization for orthopedic surgery,
presented with syncope and progressively
worsening dyspnea. On examination he
was tachypneic, hypoxemic, with elevated
D-dimer and cardiac troponin.
Transthoracic echocardiography revealed
RV dilatation and hypokinesis with
moderate tricuspid regurgitation, and an
estimate RV systolic pressure of 65 mmHg.
18. Case ReportsCase Reports
Case 1
Dopler studies of the legs showed
bilateral deep venous thrombosis,
making the diagnosis of PE likely.Urgent
contrast-enhanced CT angiograms
showed bilateral pulmonary embolism.
After treatment with intravenous rt-PA,
the patient’s status improved and
echocardiogram showed normal RV
function.
Petrov, D. et al., American Journal of Medicine Studies 1(3), 19-21, 2013
19. Case 1Case 1
Multidetector spiral computer tomogram showed
bilateral defects (arrows) in the pulmonary artery.
20. Case 1Case 1
The ECG revealed sinus tachycardia with a rate of 115 per minute, a deep S
wave in lead I, a Q wave and inverted T wave in lead III (S1
Q3
T3
syndrome).
21. Case 1Case 1
The ECG performed after completion of fibrinolysis revealed disappearance of the S
wave in lead I and slowing down of the heart rate to 78 /min.
22. Case ReportsCase Reports
Case 2Case 2
We report a 32-year-old pregnant female,
who was at 16 weeks of gestation,
presented with acute collapse and
progressive dyspnea caused by massive
PE. The diagnosis was rapidly made in the
ED with two dimensional-dopler
echocardiography that demonstrates
signs of RV dysfunction and pulmonary
hypertension, as well as direct
visualization of large thrombus at the
bifurcation of the main pulmonary artery.
23. Case ReportsCase Reports
Case 2Case 2
Because of significant haemodynamic
instability and no improvement after
intravenous heparin, the patient was
successfully treated with recombinant
tissue plasminogen activator (rt-PA) and
LMW heparin. The response to fibrinolytic
therapy was excellent without
haemorrhagic complications, and a
healthy child was born at term.
Petrov, D. et al., Hong Kong Journal of Emergency Medicine 21(4), 260, 2014
24. Case 2Case 2
Transthoracic echocardiography revealed a large saddle
thrombus at the bifurcation of the main pulmonary artery.
25. Case 2Case 2
Admission ECG showed sinus tachycardia, deep S wave
in lead I and T wave inversion in leads V1 – V4.
26. Case 2Case 2
The ECG after fibrinolysis showed reduction of the S
wave in lead I and slowing down of the heart rate.
