49âyear-old male presented with syncope and diaphoresis. Similar episode a few months ago, stress test normal at that 9me. Past Medical History: Psoriasis ...
SYNCOPE: SHOULD WE CONSIDER POSSIBILITY OF PULMONARY EMBOLISM? VIVEK BATRA HOWARD COUNTY GENERAL HOSPITAL, JOHNS HOPKINS COMMMUNITY PHYSICIANS, MARYLAND
CASE PRESENTATION 49–year-old male presented with syncope and diaphoresis Similar episode a few months ago, stress test normal at that :me Past Medical History: Psoriasis and Hyperlipidemia Medica:ons: Infliximab and methotrexate Social History: 20-pack year smoker, firefighter chief Exam. Sinus tachycardia. ECG RBBB. S1Q3, no ischemia Troponin ini:al nega:ve, subsequent rise to 0.13 ng/ml Echo: RV dysfunc:on and dila:on, LV small and vigorous contrac:on CTA: Extensive bilateral pulmonary emboli within main right and leX pulmonary arteries Treatment: Thromboly:c therapy and an:coagula:on
RADIOLOGY: CT CHEST
DIFFERENTIAL DIAGNOSIS OF SYNCOPE Defini&on: Transient, self-limited loss of consciousness due to acute global impairment of cerebral blood flow Cardiac Syncope: typically no prodrome, older pa:ent Arrhythmias: Brady-arrhythmias (AV blocks, sinus arrest), Tachy-arrhythmias (ventricular tachycardia, ventricular fibrilla:on), myocardial ischemia, Prolonged QT, Brugada syndrome Structural heart disease: Aor:c stenosis, cardiomyopathies, cardiac masses, pericardial effusion, myocardial ischemia Orthosta&c Hypotension: Blood pressure medica:ons, hemorrhage, dehydra:on, autonomic degenera:ve disorders (Parkinson), peripheral neuropathies (diabetes) Vasovagal syncope: classic prodrome of dizziness, lightheadedness, fa:gue, young pa:ent typically
PREVALENCE OF PE AMONG PATIENTS HOSPITALIZED FOR SYNCOPE: NEJM 2016, ITALIAN STUDY
PARADIGM SHIFT IN WORKUP OF SYNCOPE 17% of hospitalized pa:ents with syncope had pulmonary embolism (NEJM 2016 Italian study) Profound impact on workup of syncope: tradi:onally included history, examina:on, orthosta:c blood pressure measurement, cardiac evalua:on (telemetry, ECG, echocardiogram). Now need to consider CT of chest with IV contrast. Pulmonary embolism should be included in differen3al diagnosis of syncope Prevalence of PE was highest among pa:ents who presented with syncope of undetermined origin (25%), almost 13% of pa:ents with poten:al alterna:ve explana:on for syncope had PE
ADVANCES IN DIAGNOSIS AND TREATMENT OF PE Wells’ score (clinical suspicion, tachycardia, immobiliza:on, hemoptysis, prior DVT/ PE, cancer) is essen:al to stra:fy into low, medium and high pre-test probability d-dimer to rule out PE in low probability cases CT Chest with intravenous contrast is gold standard to confirm diagnosis V/Q scan another modality, especially with impaired renal func:on Echocardiogram: RV strain, use in massive PE/unstable pa:ents Troponin Role: myocardial damage Hemodynamics: Tachycardia and hypotension Thromboly:c Therapy Role in unstable pa:ent with RV strain, elevated troponins, or hypotension Dura:on, workup, novel an:coagulants: Current research Newer agents Direct thrombin inhibitor: dabigatran Direct factor Xa inhibitors: rivaroxaban, apixaban, and edoxaban
