{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,18]],"date-time":"2026-10-18T02:32:27Z","timestamp":1792290747317,"version":"4.4.0"},"reference-count":48,"publisher":"MDPI AG","issue":"13","license":[{"start":{"date-parts":[[2025,7,4]],"date-time":"2025-07-04T00:00:00Z","timestamp":1751587200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Chiang Mai University"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Background\/Objectives: Acute pulmonary embolism (PE) remains a leading cause of cardiovascular morbidity and mortality. Although computed tomography pulmonary angiography (CTPA) is the gold standard for diagnosis, electrocardiography (ECG) is a widely available, non-invasive tool that may provide diagnostic clues. This study aims to estimate the pooled prevalence of specific ECG abnormalities in patients with confirmed acute PE. Methods: We conducted a systematic review and meta-analysis in accordance with the PRISMA guidelines. We searched PubMed, Embase, Web of Science, Scopus, and the Cochrane Central Register of Controlled Trials until April 2024 for studies reporting prevalence data on ECG abnormalities in confirmed acute PE cases. Pooled prevalence estimates were calculated using a random-effects model, and heterogeneity was assessed using the I2 statistic. Publication bias was evaluated through funnel plots and Egger\u2019s test. Results: Twenty-four studies with 7467 patients were included. The most common ECG abnormalities were sinus tachycardia (31%, 95% CI 22\u201340%), clockwise rotation (28%, 95% CI 12\u201345%), T-wave inversion in leads V1\u2013V3 (18%, 95% CI 13\u201323%), S1Q3T3 pattern (15%, 95% CI 11\u201319%), and right bundle branch block (14%, 95% CI 10\u201317%). High heterogeneity was observed across studies, with an I2 value exceeding 95%. Publication bias was detected for both S1Q3T3 and right bundle branch block. Conclusions: Sinus tachycardia and the S1Q3T3 pattern are frequently observed in acute PE, supporting their potential use in clinical recognition. However, significant heterogeneity and publication bias highlight the need for larger, higher-quality studies with standardized ECG protocols to understand ECG\u2019s diagnostic and prognostic role in PE.<\/jats:p>","DOI":"10.3390\/jcm14134750","type":"journal-article","created":{"date-parts":[[2025,7,7]],"date-time":"2025-07-07T06:03:13Z","timestamp":1751868193000},"page":"4750","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":7,"title":["Prevalence of Electrocardiographic Abnormalities in Patients with Acute Pulmonary Embolism: A Systematic Review and Meta-Analysis"],"prefix":"10.3390","volume":"14","author":[{"given":"Sarunsorn","family":"Krintratun","sequence":"first","affiliation":[{"name":"Department of Emergency Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Wuttipong","family":"Srichuachom","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1418-0036","authenticated-orcid":false,"given":"Wachira","family":"Wongtanasarasin","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand"},{"name":"Acute Care and Emergency Medicine (ACE) Research Cluster, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2025,7,4]]},"reference":[{"key":"ref_1","first-page":"129","article-title":"Pulmonary Embolism, Part I: Epidemiology, Risk Factors and Risk Stratification, Pathophysiology, Clinical Presentation, Diagnosis and Nonthrombotic Pulmonary Embolism","volume":"18","author":"Dytrych","year":"2013","journal-title":"Exp. Clin. Cardiol."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"e2010779","DOI":"10.1001\/jamanetworkopen.2020.10779","article-title":"Comparison of 4 Acute Pulmonary Embolism Mortality Risk Scores in Patients Evaluated by Pulmonary Embolism Response Teams","volume":"3","author":"Barnes","year":"2020","journal-title":"JAMA Netw. Open"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"165","DOI":"10.1080\/13814788.2022.2086232","article-title":"A Systematic Review and Meta-Analysis of Diagnostic Delay in Pulmonary Embolism","volume":"28","author":"Rutten","year":"2022","journal-title":"Eur. J. Gen. Pract."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"589","DOI":"10.1159\/000508396","article-title":"Delayed Diagnosis in Pulmonary Embolism: Frequency, Patient Characteristics, and Outcome","volume":"99","author":"Mansella","year":"2020","journal-title":"Respiration"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"543","DOI":"10.1093\/eurheartj\/ehz405","article-title":"2019 ESC Guidelines for the Diagnosis and Management of Acute Pulmonary Embolism Developed in Collaboration with the European Respiratory Society (ERS)","volume":"41","author":"Konstantinides","year":"2020","journal-title":"Eur. Heart J."},{"key":"ref_6","doi-asserted-by":"crossref","unstructured":"Su, X.-F., Fan, N., Yang, X.-M., Song, J.-M., Peng, Q.-H., and Liu, X. (2022). A Novel Electrocardiography Model for the Diagnosis of Acute Pulmonary Embolism. Front. Cardiovasc. Med., 9.","DOI":"10.3389\/fcvm.2022.825561"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"843","DOI":"10.1183\/09031936.05.00119704","article-title":"V Prognostic Value of the ECG on Admission in Patients with Acute Major Pulmonary Embolism","volume":"25","author":"Geibel","year":"2005","journal-title":"Eur. Respir. J."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"280","DOI":"10.1016\/j.jemermed.2016.09.009","article-title":"New Electrocardiographic Changes in Patients Diagnosed with Pulmonary Embolism","volume":"52","author":"Co","year":"2017","journal-title":"J. Emerg. Med."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"e24252","DOI":"10.1002\/clc.24252","article-title":"Differentiating Electrocardiographic Indications of Massive and Submassive Pulmonary Embolism: A Cross-Sectional Study in Southern Iran from 2015 to 2020","volume":"47","author":"Bahreini","year":"2024","journal-title":"Clin. Cardiol."},{"key":"ref_10","doi-asserted-by":"crossref","unstructured":"Page, M.J., McKenzie, J.E., Bossuyt, P.M., Boutron, I., Hoffmann, T.C., Mulrow, C.D., Shamseer, L., Tetzlaff, J.M., Akl, E.A., and Brennan, S.E. (2021). The PRISMA 2020 Statement: An Updated Guideline for Reporting Systematic Reviews. PLoS Med., 18.","DOI":"10.1371\/journal.pmed.1003583"},{"key":"ref_11","doi-asserted-by":"crossref","unstructured":"Aromataris, E., and Munn, Z. (2020). Chapter 5: Systematic Reviews of Prevalence and Incidence, Faculty of Health and Medical Sciences, The University of Adelaide. JBI Manual for Evidence Synthesis.","DOI":"10.46658\/JBIRM-17-01"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"94","DOI":"10.1136\/bmj.39057.406644.68","article-title":"What Is Heterogeneity and Is It Important?","volume":"334","author":"Fletcher","year":"2007","journal-title":"BMJ"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"807","DOI":"10.1016\/S0002-9149(00)01090-0","article-title":"Diagnostic Value of the Electrocardiogram in Suspected Pulmonary Embolism","volume":"86","author":"Rodger","year":"2000","journal-title":"Am. J. Cardiol."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"281","DOI":"10.31083\/j.rcm2410281","article-title":"Algorithms of Electrocardiographic Changes for Quantitative and Localization Analysis of Thrombus Burden in Patients with Acute Pulmonary Thromboembolism","volume":"24","author":"Wang","year":"2023","journal-title":"Rev. Cardiovasc. Med."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"543","DOI":"10.1111\/anec.12163","article-title":"Electrocardiogram Patterns during Hemodynamic Instability in Patients with Acute Pulmonary Embolism","volume":"19","author":"Zhan","year":"2014","journal-title":"Ann. Noninvasive Electrocardiol."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"1185","DOI":"10.1111\/acem.14554","article-title":"Electrocardiographic Findings Associated with Early Clinical Deterioration in Acute Pulmonary Embolism","volume":"29","author":"Weekes","year":"2022","journal-title":"Acad. Emerg. Med."},{"key":"ref_17","first-page":"649","article-title":"The Prognostic Value of ST\u2212segment Elevation in the Lead AVR in Patients with Acute Pulmonary Embolism","volume":"69","author":"Kukla","year":"2011","journal-title":"Kardiol. Pol."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"e8430","DOI":"10.1097\/MD.0000000000008430","article-title":"Diagnostic Value of the Corrected QT Difference between Leads V1 and V6 in Patients with Acute Pulmonary Thromboembolism","volume":"96","author":"Park","year":"2017","journal-title":"Medicine"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"228","DOI":"10.1016\/j.jemermed.2011.07.026","article-title":"Simultaneous T-Wave Inversions in Anterior and Inferior Leads: An Uncommon Sign of Pulmonary Embolism","volume":"43","author":"Witting","year":"2012","journal-title":"J. Emerg. Med."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"46","DOI":"10.1016\/j.ejim.2023.08.028","article-title":"Prognostic Significance of Quantitative Electrocardiographic Parameters in Patients with Non-High-Risk Pulmonary Embolism","volume":"120","author":"Yan","year":"2024","journal-title":"Eur. J. Intern. Med."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"e835","DOI":"10.1016\/j.amjmed.2019.05.041","article-title":"Prognostic Value of Electrocardiography in Elderly Patients with Acute Pulmonary Embolism","volume":"132","author":"Bolt","year":"2019","journal-title":"Am. J. Med."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"257","DOI":"10.1016\/j.amjmed.2008.08.031","article-title":"Prognostic Value of ECG Among Patients with Acute Pulmonary Embolism and Normal Blood Pressure","volume":"122","author":"Vanni","year":"2009","journal-title":"Am. J. Med."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"123","DOI":"10.1016\/j.thromres.2018.01.025","article-title":"Prognostic Significance of Electrocardiogram at Presentation in Patients with Pulmonary Embolism of Different Severity","volume":"163","author":"Casazza","year":"2018","journal-title":"Thromb. Res."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"470","DOI":"10.1111\/anec.12332","article-title":"Fragmented QRS Complex Predicts In-Hospital Adverse Events and Long-Term Mortality in Patients with Acute Pulmonary Embolism","volume":"21","author":"Cetin","year":"2016","journal-title":"Ann. Noninvasive Electrocardiol."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"e12368","DOI":"10.1111\/anec.12368","article-title":"Clinical Significance of ST Elevation in Lead AVR in Acute Pulmonary Embolism","volume":"22","author":"Pourafkari","year":"2017","journal-title":"Ann. Noninvasive Electrocardiol."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"648","DOI":"10.5603\/CJ.2011.0028","article-title":"Electrocardiography and Prognosis of Patients with Acute Pulmonary Embolism","volume":"18","author":"Kukla","year":"2011","journal-title":"Cardiol. J."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"313","DOI":"10.1016\/j.jjcc.2018.12.010","article-title":"Characteristics of Synthesized Right-Sided Chest Electrocardiograms in Patients with Acute Pulmonary Embolism","volume":"73","author":"Kusayama","year":"2019","journal-title":"J. Cardiol."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"844","DOI":"10.2298\/VSP150716093O","article-title":"Gender-Related Differences in Clinical Presentation, Electrocardiography, Laboratory Markers and Outcome in Patients with Acute Embolism","volume":"73","author":"Subota","year":"2016","journal-title":"Vojnosanit. Pregl."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"121","DOI":"10.1016\/j.jemermed.2004.04.007","article-title":"Electrocardiographic Findings in Emergency Department Patients with Pulmonary Embolism","volume":"27","author":"Richman","year":"2004","journal-title":"J. Emerg. Med."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"2197","DOI":"10.1016\/j.ajem.2018.03.074","article-title":"Diagnostic Value of QRS and S Wave Variation in Patients with Suspicion of Acute Pulmonary Embolism","volume":"36","author":"Karakoyun","year":"2018","journal-title":"Am. J. Emerg. Med."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"1958","DOI":"10.1016\/j.amjcard.2013.08.030","article-title":"Relation of Electrocardiographic Changes in Pulmonary Embolism to Right Ventricular Enlargement","volume":"112","author":"Stein","year":"2013","journal-title":"Am. J. Cardiol."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"271","DOI":"10.1177\/2048872618823441","article-title":"Electrocardiography Changes and Their Significance during Treatment of Patients with Intermediate-High and High-Risk Pulmonary Embolism","volume":"9","author":"Novicic","year":"2020","journal-title":"Eur. Heart J. Acute Cardiovasc. Care"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"12","DOI":"10.1136\/postgradmedj-2018-136178","article-title":"ECG in Suspected Pulmonary Embolism","volume":"95","author":"Thomson","year":"2019","journal-title":"Postgrad. Med. J."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"212","DOI":"10.1016\/j.ajem.2015.10.028","article-title":"The Electrocardiographic Characteristics of an Acute Embolism in the Pulmonary Trunk and the Main Pulmonary Arteries","volume":"34","author":"Zhang","year":"2016","journal-title":"Am. J. Emerg. Med."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"814","DOI":"10.1002\/clc.22742","article-title":"The Value of Electrocardiography in Prognosticating Clinical Deterioration and Mortality in Acute Pulmonary Embolism: A Systematic Review and Meta-Analysis","volume":"40","author":"Qaddoura","year":"2017","journal-title":"Clin. Cardiol."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"98","DOI":"10.7326\/0003-4819-135-2-200107170-00010","article-title":"Excluding Pulmonary Embolism at the Bedside without Diagnostic Imaging: Management of Patients with Suspected Pulmonary Embolism Presenting to the Emergency Department by Using a Simple Clinical Model and d-Dimer","volume":"135","author":"Wells","year":"2001","journal-title":"Ann. Intern. Med."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"165","DOI":"10.7326\/0003-4819-144-3-200602070-00004","article-title":"Prediction of Pulmonary Embolism in the Emergency Department: The Revised Geneva Score","volume":"144","author":"Righini","year":"2006","journal-title":"Ann. Intern. Med."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"1083","DOI":"10.1016\/j.amjcard.2010.11.037","article-title":"Significance of Electrocardiographic Right Bundle Branch Block in Trained Athletes","volume":"107","author":"Kim","year":"2011","journal-title":"Am. J. Cardiol."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"304","DOI":"10.1093\/ehjacc\/zuad157","article-title":"Diagnosis and Treatment of Right Ventricular Failure Secondary to Acutely Increased Right Ventricular Afterload (Acute Cor Pulmonale): A Clinical Consensus Statement of the Association for Acute CardioVascular Care of the European Society of Cardiology","volume":"13","author":"Arrigo","year":"2024","journal-title":"Eur. Heart J. Acute Cardiovasc. Care"},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"54","DOI":"10.1177\/1024907920966520","article-title":"Diagnostic Comparison of Anterior Leads T-Wave Inversion and McGinn-White Sign in Suspected Acute Pulmonary Embolism: A Systematic Review and Meta-Analysis","volume":"30","author":"Laurentius","year":"2023","journal-title":"Hong Kong J. Emerg. Med."},{"key":"ref_41","doi-asserted-by":"crossref","unstructured":"Scridon, A. (2022). Autonomic Imbalance and Atrial Ectopic Activity-a Pathophysiological and Clinical View. Front. Physiol., 13.","DOI":"10.3389\/fphys.2022.1058427"},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"38","DOI":"10.1016\/0022-0736(87)90006-9","article-title":"Electrophysiological Mechanisms of the SI SII SIII Electrocardiographic Morphology","volume":"20","author":"Subirana","year":"1987","journal-title":"J. Electrocardiol."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"1127","DOI":"10.1111\/acem.12769","article-title":"Findings From 12-Lead Electrocardiography That Predict Circulatory Shock From Pulmonary Embolism: Systematic Review and Meta-Analysis","volume":"22","author":"Shopp","year":"2015","journal-title":"Acad. Emerg. Med."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"207","DOI":"10.1111\/anec.12278","article-title":"The Value of Electrocardiographic Abnormalities in the Prognosis of Pulmonary Embolism: A Consensus Paper","volume":"20","author":"Digby","year":"2015","journal-title":"Ann. Noninvasive Electrocardiol."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"499","DOI":"10.4070\/kcj.2010.40.10.499","article-title":"Electrocardiography Patterns and the Role of the Electrocardiography Score for Risk Stratification in Acute Pulmonary Embolism","volume":"40","author":"Ryu","year":"2010","journal-title":"Korean Circ. J."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"1804","DOI":"10.1038\/s41591-023-02396-3","article-title":"Machine Learning for ECG Diagnosis and Risk Stratification of Occlusion Myocardial Infarction","volume":"29","author":"Bouzid","year":"2023","journal-title":"Nat. Med."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"201","DOI":"10.24171\/j.phrp.2023.0337","article-title":"Number of Comorbidities and the Risk of Delay in Seeking Treatment for Coronary Heart Disease: A Longitudinal Study in Bogor City, Indonesia","volume":"15","author":"Tuminah","year":"2024","journal-title":"Osong Public Health Res. Perspect."},{"key":"ref_48","doi-asserted-by":"crossref","unstructured":"Kraik, K., Dykiert, I.A., Niewiadomska, J., Ziemer-Szyma\u0144ska, M., Miko\u0142ajczak, K., Kre\u0144, M., Kukie\u0142ka, P., Martuszewski, A., Harych, T., and Por\u0119ba, R. (2025). The Most Common Errors in Automatic ECG Interpretation. Front. Physiol., 16.","DOI":"10.3389\/fphys.2025.1590170"}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/14\/13\/4750\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,9]],"date-time":"2025-10-09T18:04:44Z","timestamp":1760033084000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/14\/13\/4750"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,7,4]]},"references-count":48,"journal-issue":{"issue":"13","published-online":{"date-parts":[[2025,7]]}},"alternative-id":["jcm14134750"],"URL":"https:\/\/doi.org\/10.3390\/jcm14134750","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,7,4]]}}}