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Is McConnell’s Sign Useful for aPE?

Ultrasound (US) is an extremely valuable tool in the evaluation of patients with suspected acute pulmonary embolism (aPE). I am planning on writing a few posts on what I think is the best way to utilize US in the evaluation of PE, and today I’m going to talk about the McConnell’s sign.  The McConnell’s sign is defined as relative hyperkinesis of the apex of the right ventricle (RV) relative to the RV free wall in the setting of RV strain. (aka enlargement).1



This finding is thought is often used to tell if a patient with an aPE has right heart strain due to massive or submassive PE. The McConnell sign was first mentioned in 1996 and that article reported that the sign had 94% specificity for aPE 1.  As should be the case with anything in medicine, there have subsequently been multiple studies that attempted to reproduce the findings of the original study.  The subsequent studies were a bit of a mixed bag.  Some studies seems to show a pretty low specificity and others seems to show a high specificity.

Check out this chart for my summary of the available literature

STUDYMETHODSRESULTSConclusion
López-candales A, Edelman K. Right ventricular outflow tract systolic excursion: a distinguishing echocardiographic finding in acute pulmonary embolism. Echocardiography. 2013;30(6):649-57.Retrospective, 60 pts.
15 w/ acute PE, 15 w/moderate chronic pHTN, 15 w/ severe chronic pHTN, 15 w/ normal pulmonary pressures
9/15 pts with aPE (60%) had McConnell sign
5/30 pts with cPH (17%) had a McConnell sign
Included all patients with McConnell's sign

Not specific for PE
Casazza F, Bongarzoni A, Capozi A, Agostoni O. Regional right ventricular dysfunction in acute pulmonary embolism and right ventricular infarction. Eur J Echocardiogr. 2005;6(1):11-4.Retrospective, 161 pts. 107 with aPE, 54 w/ RV infarction. Stats for McConnells sign:
Spc – 33%
Sns – 70%
PPV – 67%
NPV – 36%
Included all patients with McConnell's sign

Not specific for PE
Vaid U, Singer E, Marhefka GD, Kraft WK, Baram M. Poor positive predictive value of McConnell's sign on transthoracic echocardiography for the diagnosis of acute pulmonary embolism. Hosp Pract (1995). 2013;41(3):23-7.Retrospective, 73 pts with McConnells sign on echoMcConnell's sign = PPV 57% for aPEIncluded all patients with McConnell's sign

Not specific for PE
Mcconnell MV, Solomon SD, Rayan ME, Come PC, Goldhaber SZ, Lee RT. Regional right ventricular dysfunction detected by echocardiography in acute pulmonary embolism. Am J Cardiol. 1996;78(4):469-73.Original McConnell's article

Retrospective, 126 pts. Included pts with any RV dysfunction on echo, plus healthy controls.
Stats for McConnells sign:
Spc – 94%
Sns – 77%
PPV – 71%
NPV – 96%
Included all patients with RV dysfunction

Specific for PE.
Lodato JA, Ward RP, Lang RM. Echocardiographic predictors of pulmonary embolism in patients referred for helical CT. Echocardiography 2008;25:584–90. Retrospective, 67 pts who got CT for suspected PE. Stats for McConnell's sign:
Spc 96%
Sns 16%
Included only pts with suspected/confirmed PE

Specific for PE.
Dresden S, Mitchell P, Rahimi L, et al. Right ventricular dilatation on bedside echocardiography performed by emergency physicians aids in the diagnosis of pulmonary embolism. Ann Emerg Med 2014;63:16–24. Prospective, 146 pts with suspected or confirmed PE. Stats for McConnell's sign:
Spc 100% (however, only 6 pts had McConnell's sign)
Included only pts with suspected/confirmed PE

Specific for PE.
Dwyer KH, Rempell JS, Stone MB. Diagnosing centrally located pulmonary embolisms in the emergency department using point-of-care ultrasound. The American journal of emergency medicine. 2017; [PMID: 29174452]Prospective, 199 pts with suspected/confirmed PE. Stats for McConnell's sign:
Spc - 98.05%
Sns - 21.74%

+LR 11.16
Included only pts with suspected/confirmed PE

Specific for PE.
Kurzyna M, Torbicki A, Pruszczyk P. Disturbed right ventricular ejection pattern as a new Doppler echocardiographic sign of acute pulmonary embolism. The American journal of cardiology. 2002; 90(5):507-11. [PMID: 12208411]Prospective, 100 pts with suspected/confirmed PE. Stats for McConnell's sign:
100% Spc
19% Sns
Included only pts with suspected/confirmed PE

Specific for PE.

As you can see, probably the best way to use McConnell’s sign is to look for it when you have a patient with known aPE or in patients in whom you have a high suspicion of aPE. If you look at everybody who has an echo, McConnell’s sign isn’t that useful (since chronic pulmonary HTN and RV MI’s can also have it).

Check out this podcast where Mike Mallin, Ben Smith and I talk about it more in depth.

 


 

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References:

  1. Mcconnell MV, Solomon SD, Rayan ME, Come PC, Goldhaber SZ, Lee RT. Regional right ventricular dysfunction detected by echocardiography in acute pulmonary embolism. Am J Cardiol. 1996;78(4):469-73.

2 Responses to Is McConnell’s Sign Useful for aPE?

  1. AliReza says:

    Hi Jacob
    Kudos to you .

  2. Pingback: LITFL Review 333 – SimWessex

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Jacob Avila