Clinical, laboratory, roentgenographic, and electrocardiographic findings in patients with acute pulmonary embolism and no pre-existing cardiac or pulmonary disease

The history, physical examination, chest radiograph, electrocardiogram and blood gases were evaluated in patients with suspected acute pulmonary embolism (PE) and no history or evidence of pre-existing cardiac or pulmonary disease. The investigation focused upon patients with no previous cardiac or pulmonary disease in order to evaluate the clinical characteristics that were due only to PE. Acute PE was present in 117 patients and PE was excluded in 248 patients. Among the patients with PE, dyspnea or tachypnea (greater than or equal to 20/min) was present in 105 of 117 (90 percent). Dyspnea, hemoptysis, or pleuritic pain was present in 107 of 117 (91 percent). The partial pressure of oxygen in arterial blood on room air was less than 80 mm Hg in 65 of 88 (74 percent). The alveolar-arterial oxygen gradient was greater than 20 mm Hg in 76 of 88 (86 percent). The chest radiograph was abnormal in 98 of 117 (84 percent). Atelectasis and/or pulmonary parenchymal abnormalities were most common, 79 of 117 (68 percent). Nonspecific ST segment or T wave change was the most common electrocardiographic abnormality, in 44 of 89 (49 percent). Dyspnea, tachypnea, or signs of deep venous thrombosis was present in 107 of 117 (91 percent). Dyspnea or tachypnea or pleuritic pain was present in 113 of 117 (97 percent). Dyspnea or tachypnea or pleuritic pain was present in 113 of 117 (97 percent). Dyspnea or tachypnea or pleuritic pain or atelectasis or a parenchymal abnormality on the chest radiograph was present in 115 of 117 (98 percent). In conclusion, among the patients with pulmonary embolism that were identified, only a small percentage did not have these important manifestations or combinations of manifestations. Clinical evaluation, though nonspecific, is of considerable value in the selection of patients in whom there is a need for further diagnostic studies.     

老年肺动脉血栓栓塞误诊70例临床分析

目的分析老年肺动脉血栓栓塞(肺栓塞)的特点及误诊原因,以提高对老年肺栓塞的早期识别和处理。方法回顾性分析70例老年肺栓塞误诊患者的临床表现、超声心动图、心肌酶、肌钙蛋白Ⅰ、血气分析、D-二聚体、胸部X线及其他影像等临床资料,总结分析误诊的原因。结果 70例老年肺栓塞患者中,临床表现胸闷、呼吸困难57例(81.4%),胸痛27例(38.6%),咳嗽15例(21.4%),晕厥13例(18.6%),误诊疾病主要为冠心病46例(65.7%),心功能不全7例(10.0%),肺部感染5例(7.1%),慢性阻塞性肺病3例(4.3%),脑梗死3例(4.3%)。肺栓塞临床分类大面积1 9例,次大面积37例,小面积14例。结论老年肺栓塞多合并基础疾病,患者非特异性的临床症状、心电图的改变、肌钙蛋白I及心肌酶的升高、胸部X线浸润阴影为误诊主要原因。     

普胸术后肺栓塞23例临床分析

目的探讨普胸术后肺栓塞的临床特点、诊断方法和治疗措施及预后。方法对我院2000年1月～2010年10月普胸术后的肺栓塞患者23例进行临床分析。结果23例肺栓塞患者,出现呼吸困难18例,胸痛15例,咯血4例,发热5例,晕厥3例;17例经肺增强CT或CT肺动脉造影明确诊断,23例均行99MTC肺灌注扫描,表现为段性或叶性放射性稀疏或缺损。结论肺栓塞临床表现多样,诊断需结合易患因素,CT肺动脉造影、99MTC肺灌注扫描可帮助明确诊断。早期正确治疗PE,可减少死亡率。     

老年肺栓塞40例临床分析

目的 探讨老年人肺栓塞的临床特点. 方法 采用病例对照分析40例≥60岁肺栓塞患者与36例＜ 60岁肺栓塞患者的临床表现和检查特点. 结果 老年组肺栓塞患者多有基础疾病或危险因素,依次为高血压、下肢静脉血栓形成、脑梗死、冠心病、恶性肿瘤、术后卧床等,而非老年组患者半数没有基础疾病.老年肺栓塞患者常见症状为呼吸困难、胸闷,相对于非老年患者咯血和胸痛较少.部分肺栓塞患者以晕厥首发.超声心动图检查显示老年组肺栓塞患者出现肺动脉压升高、右心系统扩大和肺动脉增宽者的比例高于非老年组患者. 结论 老年肺栓塞最常见的危险因素为高血压和下肢深静脉血栓形成,其临床表现以呼吸困难首发多见.     

Gender differences in symptom presentation associated with coronary heart disease.

This study explores gender differences in symptom presentation associated with coronary heart disease (CHD). In this prospective study, nurse data collectors directly observed 550 patients as they presented to the Emergency Department (ED) of Yale-New Haven Hospital. The final sample included 217 patients (41% women) diagnosed with CHD (acute coronary ischemia or myocardial infarction). Chest pain was the most frequently reported symptom in women (70%) and men (71%). Unadjusted analyses revealed that women were more likely than men to present with midback pain (odds ratio [OR] 9.61, 95% confidence interval [CI] 2.10 to 44.11, p = 0.001), nausea and/or vomiting (OR 2.29, 95% CI 1.19 to 4.42, p = 0.012), dyspnea (OR 1.82, 95% CI 1.05 to 3.16, p = 0.032), palpitations (OR 3.42, 95% CI 1.02 to 11.47, p = 0.036), and indigestion (OR 2.13, 95% CI 1.03 to 4.44, p = 0.040). After adjustment for age and diabetes, women were more likely to present with nausea and/or vomiting (OR 2.43, 95% CI 1.23 to 4.79, p = 0.011) and indigestion (OR 2.13, 95% CI 1.10 to 4.53, p = 0.048). Women (30%) and men (29%) were equally likely to present without chest pain, and dyspnea was the most common non-chest pain symptom. In the subgroup of patients without chest pain, unadjusted analyses revealed that women were more likely to report nausea and/or vomiting compared with men (OR 4.40, 95% CI 1.30 to 14.84, p = 0.013). Although we found some significant gender differences in non-chest pain symptoms, we conclude that there were more similarities than differences in symptoms in women and men presenting to the ED with symptoms suggestive of CHD who were later diagnosed with CHD.     

Accuracy of clinical assessment in the diagnosis of pulmonary embolism

To provide clinical diagnostic criteria for pulmonary embolism (PE), we evaluated 750 consecutive patients with suspected PE who were enrolled in the Prospective Investigative Study of Acute Pulmonary Embolism Diagnosis (PISA-PED). Prior to perfusion lung scanning, patients were examined independently by six pulmonologists according to a standardized diagnostic protocol. Study design required pulmonary angiography in all patients with abnormal scans. Patients are reported as two distinct groups: a first group of 500, whose data were analyzed to derive a clinical diagnostic algorithm for PE, and a second group of 250 in whom the diagnostic algorithm was validated. PE was diagnosed by angiography in 202 (40%) of the 500 patients in the first group. A diagnostic algorithm was developed that includes the identification of three symptoms (sudden onset dyspnea, chest pain, and fainting) and their association with one or more of the following abnormalities: electrocardiographic signs of right ventricular overload, radiographic signs of oligemia, amputation of hilar artery, and pulmonary consolidations compatible with infarction. The above three symptoms (singly or in some combination) were associated with at least one of the above electrocardiographic and radiographic abnormalities in 164 (81%) of 202 patients with confirmed PE and in only 22 (7%) of 298 patients without PE. The rate of correct clinical classification was 88% (440/500). In the validation group of 250 patients the prevalence of PE was 42% (104/250). In this group, the sensitivity and specificity of the clinical diagnostic algorithm for PE were 84% (95% CI: 77 to 91%) and 95% (95% CI: 91 to 99%), respectively. The rate of correct clinical classification was 90% (225/250). Combining clinical estimates of PE, derived from the diagnostic algorithm, with independent interpretation of perfusion lung scans helps restrict the need for angiography to a minority of patients with suspected PE.     

Symptoms of acute coronary syndromes: are there gender differences? A review of the literature

Evidence has begun to accumulate that suggests there may be gender differences in the presenting symptoms of acute coronary syndromes (ACS). Identification of gender differences has implications for both health care providers and the general public. Women should be instructed as to the symptoms expected with ACS on the basis of evidence obtained from studies that include both sexes. Twelve studies that identified symptoms of ACS for both women and men were identified through a review of the literature. In several of the studies, which included all types of ACS, women had significantly more back and jaw pain, nausea and/or vomiting, dyspnea, indigestion, and palpitations. In a number of the studies, which solely sampled patients with acute myocardial infarction, women demonstrated more back, jaw, and neck pain; nausea and/or vomiting; dyspnea; palpitations; indigestion; dizziness; fatigue; loss of appetite; and syncope. Men reported more chest pain and diaphoresis in the myocardial infarction sample. Results of these studies showed that women and men experienced the same symptoms with ACS. However, in some studies there were gender differences in the proportion of symptoms. Given the current state of the science, definitive conclusions regarding gender differences in the symptoms of ACS cannot be drawn. Further study is urgently needed to clarify and expand on these findings.     

Aneurysms of the sinus of Valsalva. Report of seven cases and review of the literature

The aneurysms of the sinuses of valsalva are relatively rare. The first case was described by Thurnam in 1840. Since then, more than 200 cases have been reported; in most surgery was performed. The lesions of the aortic sinuses are either congenital or the result of the syphilis or of the bacterial endocarditis.Between 1967 and 1976, seven patients (four men and three women) with this pathology were admitted to the Hospital Cantonal of Geneva (HCG). Their ages ranged from 13 to 51 years. Clinical symptoms consisted of chest pain, palpitations, dyspnea, cardiac insufficiency and fever. In one patient, a sudden cardiovascular shock was present. Physical examination had revealed a systolic and/or diastolic thrill in four patients, and a systolic and diastolic murmur on the left sternal edge in all. An increase in the differential arterial pressure was found in all patients and hepatomegaly in two. The electrocardiograms showed signs of left ventricular hypertrophy in five patients, right ventricular hypertrophy in four, incomplete right bundle branch block in one and signs of a subendocardial ischemic lesion in another. The chest films indicated a severe or moderate heart dilatation in all seven patients and an enlarged hilar area in six.All patients had been subject to cardiac catheterization. Rightsided pressures were increased in the majority of patients. Arterial and pulmonary capillary pressures were increased in all. A correct preoperative diagnosis had been made only twice.Cardiac surgery had been performed with cardiopulmonary bypass in all patients. The aneurysm was ruptured into the right ventricle in four patients and unruptured in the others. The lesion originated from the right coronary sinus in six patients and from both right and left coronary sinuses in one. Ventricular septal defects (three) and aortic lesions (five) were also found. The postoperative course was uneventful and all patients are still alive.     

Improvement of screening for pulmonary embolism with a standardized questionnaire

The anamnesis is believed to be poor in identifying patients with pulmonary embolism (PE), but the method of data collection may be critical for inference on this issue. We compared the prevalences of history findings recorded after a free verbal interview (VI) by the referring physicians with those recorded after completion of a standardized questionnaire (SQ) by the admitting physicians in a group of 177 consecutive patients referred to our Emergency Unit with the suspicion of PE (subsequently confirmed in 97). VI data were incomplete in 18 patients. In the remaining 159 patients, prevalences of symptoms and predisposing factors were higher after SQ than after VI. Accordingly, 8 items (obesity, prolonged immobilization, surgery, varicose leg veins, deep venous thrombosis, pleuritic chest pain, and sudden-onset dyspnea) were significantly more prevalent in patients with confirmed PE after SQ, compared to only 2 items (prolonged immobilization and pleuritic chest pain) after VI. When we tested for the agreement between the two methods of data collection, kappa values ranged from high values (for surgery and hemoptysis) to very low values (for prolonged immobilization and recurrent phlebitis). These results show that the use of an SQ could improve the accuracy of collecting clinical data in patients with suspected PE, as they are also consistent in separating patients with PE from those with unconfirmed suspicion of PE. Moreover, it allows the clinician to be alert towards findings which could be missed when not carefully searched for and which may be useful to raise or strengthen the suspicion of this disease.     

Sex differences in symptoms experienced,knowledge about symptoms,symptom attribution,and perceived urgency for treatment seeking among acute coronary syndrome patients in Karachi Pakistan

BackgroundPatients’ experience of acute coronary syndrome (ACS) symptoms is important in determining their prehospital delay.ObjectiveTo explore gender differences in acute symptoms of ACS, knowledge about the symptoms, their attribution, and perception of urgency, among Pakistani ACS patients.MethodsComparative, cross-sectional study design with 249 ACS patients.ResultsThe most commonly reported symptoms were ghabrahat (fidgetiness), chest pain, and chest heaviness. Most atypical symptoms were experienced more by women, such as nausea/vomiting (p < 0.001), backache (p < 0.001), palpitations (p = 0.004), and epigastric pain (p = 0.005). Chest pain and palpitations were the symptoms most commonly attributed to cardiac causes, whereas epigastric pain was most commonly attributed to non-cardiac causes by both men and women. Significantly more women than men perceived dyspnea (p = 0.026), nausea/vomiting (p = 0.027), sweating (p = 0.014), and palpitations (p = 0.01) as symptoms not at all urgent for treatment.ConclusionsGender disparity in symptom experience along with the women's perception of non-urgency for their symptoms, could lead to delayed care seeking.     

Primary pulmonary hypertension in the elderly.

Primary pulmonary hypertension is usually considered a disease of younger adults. We reviewed the natural course of primary pulmonary hypertension in patients aged 65 years or greater. During an 8-year period, 63 elderly patients were discharged from our hospital with a diagnosis of pulmonary hypertension. In eight instances, an elevated mean pulmonary arterial pressure (greater than 25 mm Hg) could not be explained by secondary causes. These elderly patients with primary pulmonary hypertension had symptoms common to younger patients with this disease, including dyspnea (eight patients), chest pain (five), pedal edema (four), and fatigue (one). In all but one patient, the initial diagnosis was incorrect, and the patients were thought to have more common diseases of the elderly that cause similar symptoms. Coexisting medical problems were common and further obscured the correct diagnosis. Survival was significantly shorter in those patients with symptoms of less than 6 months' duration. Primary pulmonary hypertension should be considered in the differential diagnosis in elderly patients with unexplained dyspnea and chest pain.     

Cardiac hamartoma. Case report and literature review

Primary cardiac tumors are infrequent and usually benign. They can manifest as dyspnea, chest pain, palpitations, sudden death, peripheral embolism, cyanosis, or general symptoms. They are sometimes an incidental finding in an asymptomatic patient. We describe a 33-year-old man who was seen because of dyspnea and palpitations. Transthoracic echocardiography revealed, on the lateral wall of the left ventricle, an intramyocardial mass that was successfully resected surgically. The pathologic diagnosis was hamartoma of mature cardiac myocytes. We discuss the usefulness of imaging techniques for identifying cardiac masses.     

Angina intensity is not different in diabetic and non-diabetic patients with acute myocardial infarction

BACKGROUND: Diabetic patients with acute myocardial infarction (AMI) may have diminished pain or a higher frequency of asymptomatic infarctions. This appears to be a common clinical perception. METHODS: Data from two registries of AMI patients presenting in hospital (MITRA PLUS with 18786 patients; North German Registry, NGR, 1042 patients with detailed symptom interviews) were analyzed concerning symptoms of acute myocardial infarction in patients with diabetes mellitus (DM) and without diabetes (non-DM). RESULTS: DM patients were significantly older and more often female than non-DM. There were no differences in the frequency of pre-infarction angina between DM and non-DM (Mitra Plus). In NGR, severe angina during AMI occurred in 49.8% of DM and 46.3% of non-DM (n. s.). No chest pain was reported in 16.9% of DM and 15.0% of non-DM (n. s.). Extra-thoracic pain, dizziness, nausea, sweating, palpitations, radiation of angina and localization of radiating pain was not different between DM and non-DM patients. Severe dyspnea occurred in 29.5% of DM and 19.5% of non-DM patients (p = 0.003). CONCLUSIONS: Apart from a higher frequency of severe dyspnea in diabetics, there appears to be no difference in the clinical symptoms of AMI patients with and without diabetes mellitus. AMI with little or no angina was also frequently found in non-diabetics. In the hospital, diabetics with suspected AMI do not appear to need a special judgement of symptoms. This could accelerate access of diabetics to standard therapeutic procedures.     

Sudden cardiac arrest: clinical characteristics and predictors of survival

Much remains unknown about the conditions surrounding the occurrence of prehospital sudden cardiac arrest. We have investigated the clinical characteristics and predictors of survival in a total of 90 consecutive patients in whom sudden cardiac arrest (SCA) happened to occur during their hospitalization in general wards over the past 19 years. The types of arrhythmia present at the time of SCA were ventricular fibrillation (in 46% of cases), ventricular tachycardia (19%), and bradyarrhythmia (35%). The underlying causes were coronary artery disease (45%), cardiomyopathy (20%), and valvular disease (14%). SCA showed a circadian pattern, with many cases during the day and few at night. Prodromal symptoms included chest pain (16% of patients), dyspnea (11%) and palpitations (2%). Of the total of 90 subjects, 26 (29%) were discharged from hospital alive, and SCA recurred in 24% of these. The 5-year survival rate was 52%. The most important predictors of survival examined were initiation of cardiopulmonary resuscitation, NYHA class, and time of SCA. Of those in whom cardiopulmonary resuscitation was initiated within 1 min, 52% were discharged alive, but all of those not receiving it within 10 min died.     

Cardiac Munchausen syndrome

OBJECTIVE: To examine the reports on cardiac Munchausen syndrome for clinical characteristics. METHODS: Cases, case series, and related articles on the subject in all languages were identified through a comprehensive literature search. RESULTS: Fifty-eight cases of cardiac Munchausen syndrome were identified. Mean +/- SD patient age was 44 +/- 12 years (range, 23 to 71 years). Fifty-four patients (93%) were men. The most common presenting complaint was chest pain simulating acute coronary syndrome (86%). Syncope and dyspnea were also reported. Mostly, these patients were admitted directly from the emergency department to the coronary care unit. Acute myocardial infarction was the most common admitting diagnosis. The other admitting diagnoses were cardiac arrest and arrhythmia. The average number of hospital admissions for cardiac symptoms was 6 per patient (range, 1 to > 29 admissions). Numerous procedures including cardiac catheterization, coronary angiography, peripheral arteriography, permanent pacemaker placement, electrophysiological studies, intra-aortic balloon insertion, pulmonary artery catheter insertion, and electrical cardioversion have been performed in these patients. Twenty-four patients (41%) had history of undergoing prior multiple invasive procedures, but only 10 of these patients admitted having undergone these procedures. Ninety-five percent of patients altered their stories, with many leaving the hospital against medical advice when confronted with possibility of cardiac Munchausen syndrome as the correct unifying diagnosis. None of the patients reported for follow-up. CONCLUSION: Cardiac Munchausen syndrome results in unnecessary investigations and organ damage from unneeded aggressive procedures. There is scarce information available on the prognosis of these patients, especially in the long term.     

Influence of age on clinical presentation of acute pulmonary embolism

The aims of this study were to compare the clinical features of patients with pulmonary embolism (PE) and patients in whom the initial suspected diagnosis was not confirmed by the complementary studies and to determine the possible clinical differences among patients with PE according to age. A retrospective review of the charts of a group of patients with PE (n, 96) and another without PE (n, 96) was carried out. The patients with PE over 65 years of age (n, 64) were compared with those under 66 years of age (n, 32). The variables related to PE were absence of known heart disease, duration of symptoms ≤2 days, pleuritic chest pain, absence of cough, pCO₂ <4.8 kPa (36 mmHg), and normal chest X-ray. The variables associated with the existence of PE in patients over 65 years of age, when contrasted with younger patients, were female sex, absence of pleuritic chest pain, abnormal chest X-ray, hypoxemia (pO₂ < 8.7 kPa (65 mmHg) and absence of S1Q3T3 pattern in ECG.The duration of symptoms and the presence of hypocapnia, pleuritic chest pain, and normal chest X-ray may lead to the suspicion of PE. Pleuritic pain and S1Q3T3 pattern are less commonly found in old patients with PE.     

Symptoms of chest pain and dyspnea and factors associated with chest pain after coronary artery bypass grafting.

Patients in western Sweden who underwent CABG from 1988 to 1991 received prior to coronary angiography and 2 and 5 years after CABG a questionnaire, in which they were asked about symptoms of chest pain and dyspnea. In all, 1,226 patients answered the inquiry prior to CABG, 1,531 patients 2 years and 1,359 patients 5 years after surgery. Both in terms of chest pain and dyspnea there was a marked improvement 2 and 5 years after CABG as compared with prior to surgery. However, between 2 and 5 years after surgery there was a minor deterioration, both regarding chest pain and dyspnea. The most statistically significant preoperative predictors for the occurrence of chest pain more than twice a week 5 years after surgery were concomitant valvular heart disease and obesity.     

Clinical symptoms and myocardial infarction in left bundle branch block patients

In patients with left bundle branch block (LBBB) and acute chest pain, the association between the clinical presentation and the diagnosis of myocardial infarction has not been investigated. We sought to identify features in the clinical history of patients with LBBB and acute cardiopulmonary symptoms that predict myocardial infarction among candidates for reperfusion therapy. We retrospectively studied a consecutive cohort of 75 patients (94 presentations) who presented to a university emergency department from 1994 to 1997 with LBBB on initial electrocardiogram (ECG) and acute chest pain of >/=20 min duration or acute pulmonary edema. Among the 94 presentations meeting criteria for the cohort, 26 (28%) had confirmed myocardial infarction. Coronary heart disease risk factors, past cardiac history, prior LBBB on the ECG, and presenting symptoms did not predict whether patients were having myocardial infarction. The clinical history was not effective at distinguishing LBBB patients with myocardial infarction among patients who appeared to be candidates for acute reperfusion therapy.     

原发性抗磷脂抗体综合征合并肺血栓栓塞症1例并文献复习

目的：了解原发性抗磷脂抗体综合征合并肺血栓栓塞症的临床特征。方法对近期北京医院收治的1例原发性抗磷脂抗体综合征合并肺血栓栓塞症患者进行分析,并复习32例国内外文献发表的原发性抗磷脂抗体综合征合并肺血栓栓塞症病例。结果33例患者中,男18例,女15例,主要症状包括呼吸困难、胸痛、咯血和下肢疼痛等,其中合并呼吸困难、胸痛、咯血三联征的比例为42.4%,双下肢静脉血栓占38.7%,双侧肺动脉栓塞占87.1%,右房和/或右室增大者占56.3%,合并肺动脉高压者占75.0%。部分患者合并血小板减少,活化部分凝血活酶时间明显延长。及时诊断和治疗能取得良好的疗效。结论原发性抗磷脂抗体综合征合并肺血栓栓塞症患者合并三联征(胸痛、咯血、呼吸困难)的比例高,血栓范围广泛,常合并右房和/或右室扩大、血小板和凝血机制异常,及时诊断和治疗可获得良好的疗效。     

Transient right bundle branch block in a patient with acute pulmonary embolism

We report the case of an 86-year-old man found at home with acute chest pain and dyspnea. He presented some episodes of left chest pain combined with dyspnea. The physical examination revealed crackling sounds on the bases of the lungs without other anomalies. Electrocardiograms revealed a transient and complete right bundle branch block with inverted T waves in leads V1, V2, and V3. He was diagnosed with a proximal bilateral acute pulmonary embolism without acute cor pulmonale. We describe a case of a transient bundle branch block, without tachycardia or acute cor pulmonale, revealing a pulmonary embolism.