Case Presentation: A 61-year-old female with a past medical history significant for hypertension well controlled on carvedilol and left elbow fracture status post fixation 2.5 weeks prior presented to the hospital secondary to lightheadedness. Patient had been experiencing waxing and waning lightheadedness for 3 days, worse when standing from the seated position and walking. She denied any chest pain, palpitations, cough, shortness of breath, blurred vision, tinnitus, numbness, tingling, weakness, gait disturbances, syncope, nausea, or vomiting. Vitals revealed sinus tachycardia with HR 103, and patient’s physical exam was normal.A work-up completed in the ED revealed elevated troponin-I at 0.43 ng/mL. CBC, BMP, ECG, and a chest x-ray were unremarkable. Orthostatic blood pressures were normal, and an MRI of the head showed no evidence of a cerebral vascular accident. In addition, a carotid artery duplex ultrasound showed less than 50% stenosis in both internal carotid arteries. A transthoracic echocardiogram showed severe pulmonary hypertension and a dilated right ventricle. In light of these findings, a CT angiogram of the chest was performed and showed bilateral acute pulmonary embolism (PE) within the distal right main pulmonary artery and its bifurcation into the upper and lower lobes, and the left lower lobe pulmonary arteries. An ultrasound of the lower extremities was also performed and showed acute deep vein thrombosis (DVT) throughout the right superficial femoral, popliteal, and upper calf veins.The patient underwent a successful Ekosonic Endovascular System (EKOS) assisted catheter directed thrombolysis procedure the following day and was discharged home on apixaban for anticoagulation.
Discussion: PE typically presents with a combination of symptoms such as dyspnea, chest pain, and orthopnea. Less commonly, PE may present with lightheadedness, also referred to as presyncope, or syncope only. While there is limited research on the association of presyncopal episodes and PE, there are multiple studies looking at the association between syncopal episodes and PE. One study showed that nearly 1 in 6 patients hospitalized for a first episode of syncope received a diagnosis of PE. However, a later study estimated a much lower PE prevalence (1.4%) in patients presenting to the ED with syncope. Although research is limited, studies show that patients with presyncope have a much higher thirty-day mortality risk as compared to those with syncope or the more common presenting symptoms. This is possibly due to delays in diagnosis and less aggressive anticoagulation therapy.
Conclusions: This case illustrates the importance of considering PE as a potential cause of presyncope. Failure to recognize PE can lead to a delay in treatment which could have significant effects including increased mortality.