A 54-year-old man comes to the emergency department after an episode of syncope. While he was watching television 30 minutes ago, he experienced sudden-onset chest pressure followed by a syncopal episode. He regained consciousness within a minute but continues to have chest "heaviness" and shortness of breath. Two days ago, the patient returned home from an extended car trip. He has a history of hypertension, osteoarthritis, and prostate cancer treated with brachytherapy. He is a former smoker with a 15-pack-year history and does not use alcohol or illicit drugs. Temperature is 38.3 C (100.9 F), blood pressure is 81/50 mm Hg, pulse is 110/min and regular, respirations are 26/min, and pulse oximetry is 92% on room air. The lungs are clear to auscultation. Cardiac examination shows a nondisplaced point of maximal impulse, with no murmurs but an accentuated pulmonic component of S2. Laboratory results are as follows:
ECG shows sinus tachycardia with nonspecific ST-segment and T-wave changes. CT angiography reveals filling defects in the bilateral main pulmonary arteries. Blood pressure after multiple fluid boluses is 85/60 mm Hg and pulse is 108/min.
Which of the following findings in this patient is most predictive of increased 30-day mortality?

Question

A 54-year-old man comes to the emergency department after an episode of syncope.  While he was watching television 30 minutes ago, he experienced sudden-onset chest pressure followed by a syncopal episode.  He regained consciousness within a minute but continues to have chest "heaviness" and shortness of breath.  Two days ago, the patient returned home from an extended car trip.  He has a history of hypertension, osteoarthritis, and prostate cancer treated with brachytherapy.  He is a former smoker with a 15-pack-year history and does not use alcohol or illicit drugs.  Temperature is 38.3 C (100.9 F), blood pressure is 81/50 mm Hg, pulse is 110/min and regular, respirations are 26/min, and pulse oximetry is 92% on room air.  The lungs are clear to auscultation.  Cardiac examination shows a nondisplaced point of maximal impulse, with no murmurs but an accentuated pulmonic component of S2.  Laboratory results are as follows:
 ECG shows sinus tachycardia with nonspecific ST-segment and T-wave changes.  CT angiography reveals filling defects in the bilateral main pulmonary arteries.  Blood pressure after multiple fluid boluses is 85/60 mm Hg and pulse is 108/min.
Which of the following findings in this patient is most predictive of increased 30-day mortality?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c08a_b97d_8f63_9d6bcf8743a1_MD0005_00 This patient with chest pressure, syncope, and pulmonary artery filling defects on CT angiogram has a pulmonary embolism (PE) associated with hemodynamic instability, an important predictor of poor prognosis. Identifying patients at risk for adverse events is particularly important, as management options range from discharge home from the emergency department with anticoagulation to performance of embolectomy. Hemodynamic instability in acute PE is defined as persistent hypotension (systolic blood pressure <90 mm Hg), hypotension requiring vasopressors, or hypotension with evidence of end-organ damage (shock). Hemodynamic instability frequently occurs due to right ventricular dysfunction and is one of the most important predictors of increased short-term mortality. Other clinical predictors include advanced age (>80), altered mental status, history of cancer, tachypnea >30/min, tachycardia >110/min, hypothermia <36 C (96.8 F), and oxygen saturation <90%. Right ventricular dysfunction as seen on echocardiography or CT scan and laboratory abnormalities such as elevated troponin or brain natriuretic peptide levels have also been associated with worse outcomes. (Choices A, C, D, and E) Fever and a loud P2 can both occur with acute PE, and respiratory alkalosis (due to tachypnea) is the typical presentation of acute PE. However, none of these findings is associated with worse prognosis or increased mortality. Hypoxemia is common in acute PE, but levels ≥90% have not been associated with worse outcomes. Educational objective: Hemodynamic instability after pulmonary embolism is frequently due to right ventricular dysfunction and is one of the most important predictors of increased short-term mortality. Other predictors include advanced age, altered mental status, history of cancer, tachypnea, tachycardia, hypothermia, marked hypoxemia, and right ventricular dysfunction. References: The prognostic value of pulmonary embolism severity index in acute pulmonary embolism: a meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/23210843) Prognostic models in acute pulmonary embolism: a systematic review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/27130162)

A 54-Year-Old Man Comes to the Emergency Department After an Episode