Analysis of factors associated with poor R-wave progression in precordial leads in patients with acute pulmonary thromboembolism: a retrospective study

Acute pulmonary thromboembolism (APE) presents with nonspecific clinical manifestations, and the classic electrocardiogram (ECG) abnormalities associated with it have limited sensitivity. Poor R-wave progression (PRWP) is a common ECG finding linked to various cardiovascular diseases; however, the factors associated with PRWP and its clinical significance in patients with APE remain unclear. This study aims to investigate the factors related to PRWP in APE patients, providing ECG-based evidence to enhance clinical assessment. Explore the factors associated with PRWP in the precordial leads of patients with APE. This retrospective analysis included 170 patients diagnosed with APE by computed tomography pulmonary angiography (CTPA) at the People's Hospital of Ningxia Hui Autonomous Region, Ningxia Medical University, from January 2022 to December 2025. Patients were divided into two groups based on the presence of PRWP on the ECG within 24 h of admission: the PRWP group ( n = 49) and the non-PRWP group ( n = 121). Clinical characteristics, laboratory findings, and echocardiographic parameters were collected. Multivariate logistic regression analysis was performed to identify independent factors associated with PRWP. A p -value < 0.05 was considered statistically significant. Patients with PRWP had significantly higher N-terminal pro-B-type natriuretic peptide ( NT-proBNP ) (1270 vs. 430 pg/mL, P = 0.020) and tricuspid regurgitation velocity (TVR) (3.10 vs. 2.68 m/s, P = 0.017). Multivariate analysis identified TVR as the only independent correlate of PRWP (OR = 1.67, 95% CI: 1.08–2.58, P = 0.021). Subgroup analysis demonstrated that elevated NT-proBNP (≥ 200 pg/mL) was significantly associated with PRWP (OR = 3.31, 95% CI: 1.37–7.99, P = 0.008). No significant associations were observed for D-dimer, high-sensitivity C-reactive protein (hs-CRP), or cardiac chamber dimensions. TVR is independently associated with PRWP in patients with APE, and elevated NT-proBNP (≥ 200 pg/mL) also predict PRWP in subgroup analyses. The absence of chamber enlargement suggests that PRWP may reflect pressure overload before structural changes become apparent on echocardiography, indicating its potential as an early marker of right ventricular strain. Pending prospective validation, PRWP could serve as a simple ECG marker to complement existing risk stratification methods in APE patients.