(192) Syncope With STEMI

Introduction: Syncope is a reasonably simple clinical symptom to identify, only 58% of occurrences have a cause that can be identified [1]. This can be brought on by cardiac arrhythmias or cerebrovascular disease [2].

Description: A 77-year-old female with a past medical history of dementia with psychosis who presented with altered mental status with severe agitation. In the ED vitals were stable. Urinalysis was suggestive of urinary tract infection (UTI), CT brain negative for acute abnormalities, and chest x-ray negative for consolidation. She was admitted for metabolic encephalopathy secondary to UTI and was started on ceftriaxone. On the second day of admission, she had an unwitnessed syncopal episode and was minimally responsive. InitialBP was too low to be measured and the patient was given a 1L fluid bolus which improved BP to 90/50 mmHg. As part of her evaluation an ECG was performed and showed ST segment elevations in V1-V3, inverted P-waves in V1, V2, V3 showing possible left atrial enlargement. Point-of-care ultrasound (POCUS) performed at bedside showed a severely dilated right ventricle with severely reduced systolic function. Interventional cardiology was notified and the patient was taken to the cath lab. where she was found to have significant filling defects in the bilateral lower lobes as well as in the right upper lobe of the truncus arteriosus and underwent mechanical thrombectomy. Follow-up angiogram showed improvement in perfusion. Follow-up right heart catheterization showed at least a 20 mmHg lowering of PASP. Left heart catheterization revealed minimal coronary artery disease. Ultrasound of the bilateral lower extremities was negative for deep vein thrombosis. The patient made a complete recovery in the immediate post procedure time frame and was eventually discharged on Dual oral anticoagulation (DOAC).

Discussion: In the United States, recognized venous thromboembolism (VTE) causes more than 250,000 hospital admissions and over 50,000 fatalities per year [3]. Severe right heart strain secondary to PVT can lead to ST-elevation findings on EKG. Bedside POCUS can be used to quickly identify causes of acute decompensation. This in case, it helped define right heart strain despite evidence of ST elevation in Left anterior descending (LAD) territory.