American Journal of Emergency Medicine xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Recurrent presyncope episodes in an elderly patient: pulmonary embolism☆ Acute pulmonary embolism (PE) is a common and life-threatining disease in which patient's complaints may vary from nonspecific symptoms to hemodynamically unstable process. Syncope may be defined as transient loss of consciousness resolved without treatment. It has been well documented that syncope may be the first and only symptom of acute PE especially in elderly patients. Although sharing the same pathophysiologic mechanisms with syncope, loss of consciousness cannot be expected to occur in presyncope. Presyncope as an initial clinical condition in PE is a very rare clinical entity, and the literature is limited about this relation. We report a 75-year-old female patient admitted to emergency department (ED) with 5 episodes of presyncopal attacks as the initial symptom of the disease and been diagnosed with PE. Our patient represented a rare clinical presentation, which is often neglected as a result of missed diagnoses. Raised awareness of diagnosis and high clinical suspicion concerning the atypical presentation of acute PE as presyncopal attacks are very important for proper diagnosis and treatment of the disease in the EDs. Acute pulmonary embolism (PE) is a common and life-threatining disease in which patient's complaints vary from nonspecific symptoms to hemodynamically unstable state [1]. The signs and symptoms of PE may vary widely, and syncope may develop in 9% to 35% of patients with PE [2]. Presyncope can be defined as suddenly felt a sense of loss of consciousness, and as opposed to syncope, there is no real loss of consciousness in presyncope [3]. The literature has very limited data in terms of relation of presyncope and PE contrary to widely studied relation of syncope and acute PE. We report a 75-year-old female patient admitted to emergency department (ED) with 5 episodes of presyncopal attacks as the initial symptom of the disease and been diagnosed with PE. A 75-year-old female patient presented to the ED with complaints of nausea and 5 episodes of presyncope during a 3-hour period. She was operated for left femoral neck fracture 45 days ago and had been taking low-molecular-weight heparin subcutaneously 40 mg once a day for approximately 2 weeks since the date of surgery. She had a medical history of diabetes mellitus and hypertension and took oral antidiabetic drug and amlodipine for these disorders. The patient denied any urinary or fecal incontinence, chest pain, dyspnea, hemoptysis, fever, cough, lower extremity pain, or syncope. She had no history of cigarette or alcohol consumption. After admission, physical examinations revealed a body temperature of 36.7°C, pulse of 87 beats per minute, respiratory rate of 16 breaths per minute, blood pressure of 150/90 mm Hg, and oxygen saturation of 92% on room air.
☆ This case report was presented as a poster presentation at the 4th Eurasian Congress on Emergency Medicine, in Antalya, Turkey, on November 13 to 16, 2014.
The patient had a slightly haggard expression, no cyanosis of lips, and no juguler vein distention. Remarkable physical examination findings included diminished breath sounds bilaterally. Her heart rhythm was regular without murmur, and there was no edema in the lower extremities. Her neurologic and abdominal examinations including digital rectal examination were normal. Remarkable laboratory findings included a white blod cell count of 12 200 cells/mm3 (4500-11 000), hemoglobin level of 12.1 g/dL (11.7-15.5), hematocrit of 37.2%, blood glucose of 189 mg/dL (75-99), and high-sensitive troponin I of 40.28 ng/L (0-40). Blood gas analysis revealed a pH of 7.40, 56.7 mm Hg PaO2, 28.4 PaCO2, and 20.9 mmol/L HCO3 (under the condition of at a rate of 3 L/min oxygen inhalation). There were no remarkable signs on her chest radiograph, and electrocardiogram revelaed V1-V4 T-wave inversion. Acute PE was suspected and bilateral lower extremity venous color Doppler ultrasonography and enhanced spiral chest computed tomographic (CT) scanning were planned for the diagnosis. Color ultrasonography revealed no evidence of thrombus formation. An enhanced CT scan revealed filling defects in the right and left superior pulmonary arteries as well as bilateral atelectatic areas (Figure). After the diagnosis of PE was determined, intravenous heparin infusion was initiated in the ED, and the patient was admitted to the intensive care unit. The patient was discharged from hospital 14 days after admission, with continued daily administration of 2.5 mg warfarin. The most common symptoms of PE are dyspnea, chest pain, cough, and syncope [1]. Syncope may be detected in 9% to 35% of PE patients as the first manifestation of the disease [2]. Syncope and PE relation is explained by 3 posssible mechanisms in general: reduction in cerebral blood flow and hypotension due to a decrease in cardiac output [4], reflex syncope occurring secondarily to bradycardia [4], and cardiac arrhythmias and conduction disturbances [5,6]. Hypotension or arrhytmias were not present in the case presented. In a clinical study that investigated clinical features of PE in elderly patients (≥75 years), syncope was more frequent in elderly, whereas thoracic pain predominated in younger patients [7]. In addition, chronic obstructive pulmonary disease was more frequent, and the diagnosis of PE was less suspected in elderly patients [7]. Identification of syncopal event as the cause of PE especially in elderly patients is often difficult for ED physicians. Analysis of 335 patients with acute PE (36 had syncope at presentation) revealed that frequency of right ventricular dysfunction, saddletype embolism, and a history of previous PE were higher in patients with syncope compared to patients without syncope [8]. According to this study, there was no difference between the groups in terms of inhospital mortality [8]. In a similar but retrospective study from Russia that assessed the value of syncope in PE, it was revelaled that fatal outcomes, massive PE on CT scans, number of patients receiving
0735-6757/© 2015 Elsevier Inc. All rights reserved.
Please cite this article as: Guler S, et al, Recurrent presyncope episodes in an elderly patient: pulmonary embolism, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.03.064
2
S. Guler et al. / American Journal of Emergency Medicine xxx (2015) xxx–xxx
bolism [10]. Immobilization and surgery within the last 3 months were the risk factors that we established in our patient. In conclusion, the occurrence of presyncope as the sole initial symptom of PE in an elderly patient with no hemodynamic instability is extremely rare. Raised awareness of diagnosis and high clinical suspicion concerning the atypical presentation of acute PE as in our case are very important for immediate diagnosis and appropriate treatment of acute PE in the EDs. Sertac Guler MD ⁎ Nazif Onur Olcay MD Bahar Gulcay Cat Bakır MD Department of Emergency Medicine, Ankara Training and Research Hospital Ankara, Turkey ⁎Corresponding author at: Department of Emergency Medicine, Ankara Training and Research Hospital, Ankara, Turkey. Tel.: +90 532 554 83 88 E-mail address: [email protected] Yavuz Katırcı MD Department of Emergency Medicine, Ankara Training and Research Hospital Ankara, Turkey Figure. Enhanced chest CT scan revealing filling defects in the right and left superior pulmonary artery branches.
thrombolytic therapy, and inhospital mortality were more frequent in patients who experienced 1 syncopal event than those without syncope [2]. Our patient did not receive thrombolytic therapy and was discharged from hospital without any complication. Presyncope in PE is a very rare clinical entity, and the literature is poor on this subject. Although presyncope seems to syncope, most published studies combined the 2 conditions. During presyncope, the patient experiences 1 or more of the prodromal symptoms of syncope but recovers before losing consciousness. The absence of loss of consciousness is the major difference of presyncope from syncope [3]. In a prospective cohort study that examined 881 patients presenting to ED with presyncope, 2 of them were diagnosed with PE [9]. According to aferomentioned study presyncope constituted 0.5% of ED visits and can be caused by serious underlying conditions such as arrhyhtmia, myocardial infarction, PE, and hemorrhage [9]. Our patient represented a rare clinical presentation, which is often neglected as a result of missed diagnoses. Considering that presyncope is rare and atypical symptom in PE and its duration of onset and number of attacks, the patient may easily has been misdiagnosed with cardiac or nervous system disease. Risk factors of PE may include immobilization, surgery or central venous instrumentation within the last 3 months, stroke, paralysis, malignancy, chronic heart disease, and a history of venous thromboem-
http://dx.doi.org/10.1016/j.ajem.2015.03.064 References [1] Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P, et al. Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). Eur Heart J 2008;29:2276–315. [2] Duplyakov D, Kurakina E, Pavlova T, Khokhlunov S, Surkova E. Value of syncope in patients with high-to-intermediate risk pulmonary artery embolism. Eur Heart J Acute Cardiovasc Care 2014. http://dx.doi.org/10.1177/2048872614527837. [3] Moya A, Sutton R, Ammirati F, Blanc JJ, Brignole M, Dahm JB, et al. Guidelines for the diagnosis and management of syncope (version 2009). Eur Heart J 2009;30:2631–71. [4] Eldadah ZA, Najjar SS, Ziegelstein RC. A patient with syncope, only “vagally” related to the heart. Chest 2000;117:1801–3. [5] Elias J, Kuniyoshi R, Moulin B, Cunha F, Castro E, Nunes A, et al. Syncope and complete atrioventricular block related to pulmonary thromboembolism. Arq Bras Cardiol 2004;83:438–41 [434–7]. [6] Wilner C, Garnier-Crussard JP, Huygue De Mahenge A, Gayet C, André-Fouet X, Pont M. Paroxysmal atrioventricular block, cause of syncope in pulmonary embolism. 2 cases. Presse Med 1983;12:2987–9. [7] Tisserand G, Gil H, Méaux-Ruault N, Magy-Bertrand N. Clinical features of pulmonary embolism in elderly: a comparative study of 64 patients. Rev Med Interne 2014;35: 353–6. [8] Jenab Y, Lotfi-Tokaldany M, Alemzadeh-Ansari MJ, Seyyedi SR, Shirani S, Soudaee M, et al. Correlates of syncope in patients with acute pulmonary thromboembolism. Clin Appl Thromb Hemost 2014. http://dx.doi.org/10.1177/1076029614540037. [9] Thiruganasambandamoorthy V, Stiell IG, Wells GA, Vaidyanathan A, Mukarram M, Taljaard M. Outcomes in presyncope patients: a prospective cohort study. Ann Emerg Med 2014. http://dx.doi.org/10.1016/j.annemergmed.2014.07.452. [10] Stein PD, Beemath A, Matta F, Weg JG, Yusen RD, Hales CA, et al. Clinical characteristics of patients with acute pulmonary embolism: data from PIOPED II. Am J Med 2007;120:871–9.
Please cite this article as: Guler S, et al, Recurrent presyncope episodes in an elderly patient: pulmonary embolism, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.03.064
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Recurrent presyncope episodes in an elderly patient: pulmonary embolism☆ Acute pulmonary embolism (PE) is a common and life-threatining disease in which patient's complaints may vary from nonspecific symptoms to hemodynamically unstable process. Syncope may be defined as transient loss of consciousness resolved without treatment. It has been well documented that syncope may be the first and only symptom of acute PE especially in elderly patients. Although sharing the same pathophysiologic mechanisms with syncope, loss of consciousness cannot be expected to occur in presyncope. Presyncope as an initial clinical condition in PE is a very rare clinical entity, and the literature is limited about this relation. We report a 75-year-old female patient admitted to emergency department (ED) with 5 episodes of presyncopal attacks as the initial symptom of the disease and been diagnosed with PE. Our patient represented a rare clinical presentation, which is often neglected as a result of missed diagnoses. Raised awareness of diagnosis and high clinical suspicion concerning the atypical presentation of acute PE as presyncopal attacks are very important for proper diagnosis and treatment of the disease in the EDs. Acute pulmonary embolism (PE) is a common and life-threatining disease in which patient's complaints vary from nonspecific symptoms to hemodynamically unstable state [1]. The signs and symptoms of PE may vary widely, and syncope may develop in 9% to 35% of patients with PE [2]. Presyncope can be defined as suddenly felt a sense of loss of consciousness, and as opposed to syncope, there is no real loss of consciousness in presyncope [3]. The literature has very limited data in terms of relation of presyncope and PE contrary to widely studied relation of syncope and acute PE. We report a 75-year-old female patient admitted to emergency department (ED) with 5 episodes of presyncopal attacks as the initial symptom of the disease and been diagnosed with PE. A 75-year-old female patient presented to the ED with complaints of nausea and 5 episodes of presyncope during a 3-hour period. She was operated for left femoral neck fracture 45 days ago and had been taking low-molecular-weight heparin subcutaneously 40 mg once a day for approximately 2 weeks since the date of surgery. She had a medical history of diabetes mellitus and hypertension and took oral antidiabetic drug and amlodipine for these disorders. The patient denied any urinary or fecal incontinence, chest pain, dyspnea, hemoptysis, fever, cough, lower extremity pain, or syncope. She had no history of cigarette or alcohol consumption. After admission, physical examinations revealed a body temperature of 36.7°C, pulse of 87 beats per minute, respiratory rate of 16 breaths per minute, blood pressure of 150/90 mm Hg, and oxygen saturation of 92% on room air.
☆ This case report was presented as a poster presentation at the 4th Eurasian Congress on Emergency Medicine, in Antalya, Turkey, on November 13 to 16, 2014.
The patient had a slightly haggard expression, no cyanosis of lips, and no juguler vein distention. Remarkable physical examination findings included diminished breath sounds bilaterally. Her heart rhythm was regular without murmur, and there was no edema in the lower extremities. Her neurologic and abdominal examinations including digital rectal examination were normal. Remarkable laboratory findings included a white blod cell count of 12 200 cells/mm3 (4500-11 000), hemoglobin level of 12.1 g/dL (11.7-15.5), hematocrit of 37.2%, blood glucose of 189 mg/dL (75-99), and high-sensitive troponin I of 40.28 ng/L (0-40). Blood gas analysis revealed a pH of 7.40, 56.7 mm Hg PaO2, 28.4 PaCO2, and 20.9 mmol/L HCO3 (under the condition of at a rate of 3 L/min oxygen inhalation). There were no remarkable signs on her chest radiograph, and electrocardiogram revelaed V1-V4 T-wave inversion. Acute PE was suspected and bilateral lower extremity venous color Doppler ultrasonography and enhanced spiral chest computed tomographic (CT) scanning were planned for the diagnosis. Color ultrasonography revealed no evidence of thrombus formation. An enhanced CT scan revealed filling defects in the right and left superior pulmonary arteries as well as bilateral atelectatic areas (Figure). After the diagnosis of PE was determined, intravenous heparin infusion was initiated in the ED, and the patient was admitted to the intensive care unit. The patient was discharged from hospital 14 days after admission, with continued daily administration of 2.5 mg warfarin. The most common symptoms of PE are dyspnea, chest pain, cough, and syncope [1]. Syncope may be detected in 9% to 35% of PE patients as the first manifestation of the disease [2]. Syncope and PE relation is explained by 3 posssible mechanisms in general: reduction in cerebral blood flow and hypotension due to a decrease in cardiac output [4], reflex syncope occurring secondarily to bradycardia [4], and cardiac arrhythmias and conduction disturbances [5,6]. Hypotension or arrhytmias were not present in the case presented. In a clinical study that investigated clinical features of PE in elderly patients (≥75 years), syncope was more frequent in elderly, whereas thoracic pain predominated in younger patients [7]. In addition, chronic obstructive pulmonary disease was more frequent, and the diagnosis of PE was less suspected in elderly patients [7]. Identification of syncopal event as the cause of PE especially in elderly patients is often difficult for ED physicians. Analysis of 335 patients with acute PE (36 had syncope at presentation) revealed that frequency of right ventricular dysfunction, saddletype embolism, and a history of previous PE were higher in patients with syncope compared to patients without syncope [8]. According to this study, there was no difference between the groups in terms of inhospital mortality [8]. In a similar but retrospective study from Russia that assessed the value of syncope in PE, it was revelaled that fatal outcomes, massive PE on CT scans, number of patients receiving
0735-6757/© 2015 Elsevier Inc. All rights reserved.
Please cite this article as: Guler S, et al, Recurrent presyncope episodes in an elderly patient: pulmonary embolism, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.03.064
2
S. Guler et al. / American Journal of Emergency Medicine xxx (2015) xxx–xxx
bolism [10]. Immobilization and surgery within the last 3 months were the risk factors that we established in our patient. In conclusion, the occurrence of presyncope as the sole initial symptom of PE in an elderly patient with no hemodynamic instability is extremely rare. Raised awareness of diagnosis and high clinical suspicion concerning the atypical presentation of acute PE as in our case are very important for immediate diagnosis and appropriate treatment of acute PE in the EDs. Sertac Guler MD ⁎ Nazif Onur Olcay MD Bahar Gulcay Cat Bakır MD Department of Emergency Medicine, Ankara Training and Research Hospital Ankara, Turkey ⁎Corresponding author at: Department of Emergency Medicine, Ankara Training and Research Hospital, Ankara, Turkey. Tel.: +90 532 554 83 88 E-mail address: [email protected] Yavuz Katırcı MD Department of Emergency Medicine, Ankara Training and Research Hospital Ankara, Turkey Figure. Enhanced chest CT scan revealing filling defects in the right and left superior pulmonary artery branches.
thrombolytic therapy, and inhospital mortality were more frequent in patients who experienced 1 syncopal event than those without syncope [2]. Our patient did not receive thrombolytic therapy and was discharged from hospital without any complication. Presyncope in PE is a very rare clinical entity, and the literature is poor on this subject. Although presyncope seems to syncope, most published studies combined the 2 conditions. During presyncope, the patient experiences 1 or more of the prodromal symptoms of syncope but recovers before losing consciousness. The absence of loss of consciousness is the major difference of presyncope from syncope [3]. In a prospective cohort study that examined 881 patients presenting to ED with presyncope, 2 of them were diagnosed with PE [9]. According to aferomentioned study presyncope constituted 0.5% of ED visits and can be caused by serious underlying conditions such as arrhyhtmia, myocardial infarction, PE, and hemorrhage [9]. Our patient represented a rare clinical presentation, which is often neglected as a result of missed diagnoses. Considering that presyncope is rare and atypical symptom in PE and its duration of onset and number of attacks, the patient may easily has been misdiagnosed with cardiac or nervous system disease. Risk factors of PE may include immobilization, surgery or central venous instrumentation within the last 3 months, stroke, paralysis, malignancy, chronic heart disease, and a history of venous thromboem-
http://dx.doi.org/10.1016/j.ajem.2015.03.064 References [1] Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P, et al. Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). Eur Heart J 2008;29:2276–315. [2] Duplyakov D, Kurakina E, Pavlova T, Khokhlunov S, Surkova E. Value of syncope in patients with high-to-intermediate risk pulmonary artery embolism. Eur Heart J Acute Cardiovasc Care 2014. http://dx.doi.org/10.1177/2048872614527837. [3] Moya A, Sutton R, Ammirati F, Blanc JJ, Brignole M, Dahm JB, et al. Guidelines for the diagnosis and management of syncope (version 2009). Eur Heart J 2009;30:2631–71. [4] Eldadah ZA, Najjar SS, Ziegelstein RC. A patient with syncope, only “vagally” related to the heart. Chest 2000;117:1801–3. [5] Elias J, Kuniyoshi R, Moulin B, Cunha F, Castro E, Nunes A, et al. Syncope and complete atrioventricular block related to pulmonary thromboembolism. Arq Bras Cardiol 2004;83:438–41 [434–7]. [6] Wilner C, Garnier-Crussard JP, Huygue De Mahenge A, Gayet C, André-Fouet X, Pont M. Paroxysmal atrioventricular block, cause of syncope in pulmonary embolism. 2 cases. Presse Med 1983;12:2987–9. [7] Tisserand G, Gil H, Méaux-Ruault N, Magy-Bertrand N. Clinical features of pulmonary embolism in elderly: a comparative study of 64 patients. Rev Med Interne 2014;35: 353–6. [8] Jenab Y, Lotfi-Tokaldany M, Alemzadeh-Ansari MJ, Seyyedi SR, Shirani S, Soudaee M, et al. Correlates of syncope in patients with acute pulmonary thromboembolism. Clin Appl Thromb Hemost 2014. http://dx.doi.org/10.1177/1076029614540037. [9] Thiruganasambandamoorthy V, Stiell IG, Wells GA, Vaidyanathan A, Mukarram M, Taljaard M. Outcomes in presyncope patients: a prospective cohort study. Ann Emerg Med 2014. http://dx.doi.org/10.1016/j.annemergmed.2014.07.452. [10] Stein PD, Beemath A, Matta F, Weg JG, Yusen RD, Hales CA, et al. Clinical characteristics of patients with acute pulmonary embolism: data from PIOPED II. Am J Med 2007;120:871–9.
Please cite this article as: Guler S, et al, Recurrent presyncope episodes in an elderly patient: pulmonary embolism, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.03.064
