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Various prognostic scoring systems (e.g., PESI, sPESI) can help stratify patients with pulmonary embolism (PE) to determine their risk for adverse outcomes. However, syncope and presyncope aren't included as risk factors within these stratification models. In this multicenter Italian cohort of >1700 patients with acute PE, 30-day mortality was 16% (consistent with prior studies; e.g., Arch Intern Med 2008; 168:425). Syncope and presyncope incidences were 13% and 14%, respectively.
Thirty-day mortality for PE patients who presented with syncope or presyncope was significantly higher than that of patients without syncope or presyncope (43% vs. 6%), and excess mortality was not explained fully by between-group differences in other known markers of mortality in PE (e.g., hypotension or shock and elevated troponin levels were significantly more common in patients who presented with syncope or presyncope). Surprisingly, PE patients with presyncope had a significantly higher 30-day mortality than did patients with syncope (47% vs. 37%), possibly because less-aggressive thrombolytic therapy was applied in the presyncope group.
Roncon L et al. Impact of syncope and pre-syncope on short-term mortality in patients with acute pulmonary embolism. Eur J Intern Med 2018 Apr 11; [e-pub]. (https://doi.org/10.1016/j.ejim.2018.04.004)
Comment
In another recent study, researchers evaluated the prevalence of PE in patients with syncope (NEJM JW Gen Med Nov 15 2016 and N Engl J Med 2016; 375:1524). In contrast, in this current study, researchers assessed the prevalence and prognostic implications of syncope or presyncope as a presenting manifestation of PE and showed that this presentation portended very high 30-day mortality. Clinicians should evaluate right ventricular function in such patients and monitor them closely in the inpatient setting while therapy is initiated.