ECG Findings of Pulmonary Embolism (PE)
1. Sinus Tachycardia (Most Common Finding)
• Most frequent ECG abnormality in acute PE
• Heart rate usually >100 bpm
• Reflects hypoxia, pain, anxiety, and sympathetic activation
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2. S1Q3T3 Pattern (McGinn–White Sign)
• Deep S wave in Lead I
• Q wave in Lead III
• T-wave inversion in Lead III
• Suggests acute right heart strain
• Seen in <20% cases (not sensitive but classic for exams)
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3. Right Heart Strain Pattern
• T-wave inversion in V1–V4
• T-wave inversion in inferior leads (II, III, aVF)
• Reflects acute RV pressure overload
• Associated with worse prognosis
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4. Right Bundle Branch Block (RBBB)
• Incomplete or complete RBBB
• rSR′ pattern in V1
• Wide QRS if complete (>120 ms)
• Caused by acute RV dilation
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5. Right Axis Deviation
• QRS axis > +90°
• Dominant R wave in lead III
• Reflects RV strain
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6. P Pulmonale (Right Atrial Enlargement)
• Tall peaked P wave (>2.5 mm) in lead II
• Indicates acute right atrial pressure rise
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7. Atrial Arrhythmias
• Atrial fibrillation
• Atrial flutter
• Atrial tachycardia
Occur due to acute right atrial strain
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Less Common but Important Findings
• ST elevation in V1 (mimics anterior MI)
• Diffuse ST depression
• Clockwise rotation
• Low voltage (rare)
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High-Risk ECG Pattern in Massive PE
Combination of:
• Sinus tachycardia
• S1Q3T3
• RBBB
• T-wave inversion V1–V4
Suggests significant RV dysfunction and hemodynamic compromise
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Key Clinical Point
ECG in PE is neither sensitive nor specific.
Normal ECG does not rule out PE.
ECG mainly helps:
• Assess severity
• Identify RV strain
• Exclude alternative diagnoses (e.g., STEMI, pericarditis)
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