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Communications to the Editor |

A Diagnostic Dilemma of Syncope FREE TO VIEW

Davinder S. Jassal, MD; Richard Lodge, MB
Author and Funding Information

Dalhousie University Halifax, NS, Canada

Correspondence to: Davinder S. Jassal, MD, Division of Cardiology, Queen Elizabeth II Health Sciences Center, Room 2134–1796 Summer St, Halifax, NS, Canada B3K 6A3; e-mail: umjassal@hotmail.com



Chest. 2002;121(4):1377-1378. doi:10.1378/chest.121.4.1377
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To the Editor:

We read with interest the article in CHEST by Zayd Eldadah et al (June 2000),1 illustrating the first known case report of a patient with pulmonary embolism presenting as syncope, due to high-grade atrioventricular node dysfunction. We describe a similar case of a previously healthy 76-year-old man who presented with syncope and transient sinus node dysfunction secondary to chronic bilateral thromboemboli of the main pulmonary arteries.

A 76-year-old man presented with a witnessed syncopal episode of 2-min duration. There were no symptoms suggestive of a seizure. On transport to the hospital, marked bradycardia with sinus pauses were noted by the paramedics on the telemetric monitor. On arrival, the patient was afebrile, normotensive, with a normal heart rate. The cardiorespiratory examination revealed findings compatible with pulmonary hypertension. There was no calf or thigh swelling or tenderness.

The cell blood count, electrolytes, coagulation parameters, urinalysis, and chest radiography were noncontributory. The ECG demonstrated first-degree atrioventricular block with no evidence of ischemia. As the possibility of a cardiac etiology for syncope was entertained, the patient was admitted to the hospital for continuous telemetry and serial cardiac enzymes, the results of both of which were negative. The patient underwent two-dimensional echocardiography that confirmed moderate-to-severe tricuspid regurgitation, with an estimated pulmonary systolic pressure of 90 to 99 mm Hg. Bilateral compression ultrasound of the legs revealed no evidence of deep venous thrombosis. The patient subsequently underwent an infused spiral CT of the chest, which demonstrated bilateral chronic pulmonary emboli in the main pulmonary arteries with acute pulmonary embolism in the left segment (Fig 1 ). The patient was later identified as heterozygous for the factor V Leiden mutation. The patient received anticoagulation with unfractionated heparin, and warfarin therapy was initiated for life.

Our case is notable for transient sinus node dysfunction as a cause of syncope in the setting of acute pulmonary embolism on chronic thromboembolic disease, similar to the Bezold-Jarisch vasodepressor reflex described by Eldadah et al.1The patient’s complete lack of symptoms for either acute or chronic pulmonary embolism, aside from syncope, is unique. Although pulmonary thromboendarterectomy offers patients with chronic pulmonary hypertension an improvement in their functional status, the utility of this option in our patient with a single episode of syncope is unknown.2

Both of these cases remind us that one should entertain the diagnosis of pulmonary embolism, acute and chronic, in any patient presenting with syncope.

Figure Jump LinkFigure 1. Infused spiral CT of the chest demonstrating an acute on chronic pulmonary embolus in the left main pulmonary artery (arrow).Grahic Jump Location
Eldadah, ZA, Najjar, SS, Ziegelstein, RC (2000) A patient with syncope, only “vagally” related to the heart.Chest117,1801-1803. [PubMed] [CrossRef]
 
Fedullo, PF, Auger, WR, Channick, RN, et al Chronic thromboembolic pulmonary hypertension.Clin Chest Med1995;16,353-374. [PubMed]
 

Figures

Figure Jump LinkFigure 1. Infused spiral CT of the chest demonstrating an acute on chronic pulmonary embolus in the left main pulmonary artery (arrow).Grahic Jump Location

Tables

References

Eldadah, ZA, Najjar, SS, Ziegelstein, RC (2000) A patient with syncope, only “vagally” related to the heart.Chest117,1801-1803. [PubMed] [CrossRef]
 
Fedullo, PF, Auger, WR, Channick, RN, et al Chronic thromboembolic pulmonary hypertension.Clin Chest Med1995;16,353-374. [PubMed]
 
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