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Pulmonary embolism manifesting as acute coronary syndrome: a case reportYilu Feng1, Xiaofang Zeng1, Tangzhiming Li2, Yiyang Tang1, Qin Chen1, Zaixin Yu1*Authors’ affiliations: 1Department of Cardiology, Xiangya Hospital, Central South University, Xiangya Road, Changsha 410008, People's Republic of China2Department of Cardiology, Shenzhen People's Hospital, Second Clinical Medical College of Jinan University, First Affiliated Hospital of Southern University of Science and Technology , 1017 Dongmen North Road, Shenzhen, Guangdong, ChinaCorresponding authorsZaixin Yu, Ph.D.Address: Department of Cardiology, Xiangya Hospital, Central South University, Changsha, Hunan 410008, Chinae-mail: yuzaixin@Phone number: +86-0731-84327492Conflict of interest disclosure statement: The authors declare no potential conflicts of interest.AbstractBackground: Acute pulmonary embolism (PE) is a life-threatening clinical emergency that is easily overlooked. Hence, timely identification and intervention are required.Case presentation: Our 69-year-old female patient admitted to the Xiangya hospital with chest tightness and shortness of breath for three days, worsening for one day. An electrocardiography (ECG) obtained in the emergency room showed ST-segment elevation in aVR lead and depression in other ten leads (besides V1 lead). Laboratory examination revealed elevated white blood cell count (WBC) and biomarkers of myocardial injury. Based on her clinical symptoms and examination results, the clinicians suspected acute coronary syndrome (ACS). However, her coronary angiography (CAG) showed coronary atherosclerosis with slight stenosis. Therefore, she transferred to cardiology department. The ultrasonic cardiogram reported the presence of PE features - widened pulmonary arteries and elevated pulmonary artery pressure (SPAP 62mmHg). Further CT pulmonary angiography showed multiple filling defects of the pulmonary artery and lung perfusion examination showed multiple lung perfusion damage in both lungs. Following the final diagnosis, we gave targeted treatments, the patient's shortness of breath improved significantly.Conclusion: This case report emphasizes the clinical value of ultrasonic cardiogram in diagnosis PE and call on clinicians to raise awareness of PE.Keywords: Acute pulmonary embolism; electrocardiography; ultrasonic cardiogram; case reportAbbreviationsPE: pulmonary embolismECG: electrocardiographyWBC: white blood cell countACS: acute coronary syndromeCAG: coronary angiographySPAP: systolic pulmonary artery pressureNSTEMI: non-ST-segment elevation myocardial infarctionCTPA: computer tomography pulmonary angiographyPESI: pulmonary embolism severity indexRV: right ventricleIntroductionPulmonary embolism (PE) is a common cardiovascular disease, with a three-month mortality rate of up to 10%PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Ib3dhcmQ8L0F1dGhvcj48WWVhcj4yMDE5PC9ZZWFyPjxS

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ADDIN EN.CITE.DATA 3. The clinical manifestations of PE are atypical, the most common presentation includes shortness of breath, acute dyspnea, pleuritic chest pain and hemoptysis, similar to ACS, pleurisy, pneumonia and chronic obstructive pulmonary diseases. In clinical practice, PE often missed diagnosis ADDIN EN.CITE <EndNote><Cite><Author>Han</Author><Year>2019</Year><RecNum>284</RecNum><DisplayText><style face="superscript">4</style></DisplayText><record><rec-number>284</rec-number><foreign-keys><key app="EN" db-id="f9f5pve5eez223eafwup5rzez0xt0p90pv0e" timestamp="1607882293">284</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Han, Y.</author><author>Gong, Y.</author></authors></contributors><auth-address>The Second Clinical Institute, Southern Medical University.&#xD;Department of Respiratory, Zhujiang Hospital of Southern Medical University, Guangzhou, China.</auth-address><titles><title>Pulmonary embolism with abdominal pain as the chief complaint: A case report and literature review</title><secondary-title>Medicine (Baltimore)</secondary-title></titles><periodical><full-title>Medicine (Baltimore)</full-title></periodical><pages>e17791</pages><volume>98</volume><number>44</number><edition>2019/11/07</edition><keywords><keyword>Abdominal Pain/*diagnosis/etiology</keyword><keyword>Diagnosis, Differential</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Pulmonary Embolism/complications/*diagnosis</keyword></keywords><dates><year>2019</year><pub-dates><date>Nov</date></pub-dates></dates><isbn>1536-5964 (Electronic)&#xD;0025-7974 (Linking)</isbn><accession-num>31689854</accession-num><urls><related-urls><url> or misdiagnosis ADDIN EN.CITE <EndNote><Cite><Author>Zelfani</Author><Year>2019</Year><RecNum>283</RecNum><DisplayText><style face="superscript">5</style></DisplayText><record><rec-number>283</rec-number><foreign-keys><key app="EN" db-id="f9f5pve5eez223eafwup5rzez0xt0p90pv0e" timestamp="1607882032">283</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Zelfani, S.</author><author>Manai, H.</author><author>Laabidi, S.</author><author>Wahabi, A.</author><author>Akeri, S.</author><author>Daghfous, M.</author></authors></contributors><auth-address>Pre Hospital Emergency Department (SAMU 01), Emergency Medical Help Center of Tunis, Tunis, Tunisia.</auth-address><titles><title>Pulmonary embolism mimicking acute myocardial infarction: a case report and review of literature</title><secondary-title>Pan Afr Med J</secondary-title></titles><periodical><full-title>Pan Afr Med J</full-title></periodical><pages>275</pages><volume>33</volume><edition>2019/11/07</edition><keywords><keyword>Adult</keyword><keyword>Chest Pain/*diagnosis/etiology</keyword><keyword>Computed Tomography Angiography</keyword><keyword>Diagnosis, Differential</keyword><keyword>Echocardiography</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Myocardial Infarction/*diagnosis</keyword><keyword>Pulmonary Embolism/*diagnosis</keyword><keyword>Myocardial infarction</keyword><keyword>electrocardiography</keyword><keyword>pulmonary thromboembolism</keyword></keywords><dates><year>2019</year></dates><isbn>1937-8688 (Electronic)</isbn><accession-num>31692844</accession-num><urls><related-urls><url>, leading to delays in the rescue of patients and affecting the quality of life of patientsPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CYWphajwvQXV0aG9yPjxZZWFyPjIwMTU8L1llYXI+PFJl

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ADDIN EN.CITE.DATA 8. In terms of clinical differential diagnosis, it is limited by doctors' clinical diagnosis experience, medical diagnosis equipment and other factors, resulting in about 35% of PE patients are not treated in time every year and the misdiagnosis rate of PE is as high as 85% ADDIN EN.CITE <EndNote><Cite><Author>den Exter</Author><Year>2013</Year><RecNum>279</RecNum><DisplayText><style face="superscript">9</style></DisplayText><record><rec-number>279</rec-number><foreign-keys><key app="EN" db-id="f9f5pve5eez223eafwup5rzez0xt0p90pv0e" timestamp="1607878122">279</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>den Exter, P. L.</author><author>van Es, J.</author><author>Erkens, P. M.</author><author>van Roosmalen, M. J.</author><author>van den Hoven, P.</author><author>Hovens, M. M.</author><author>Kamphuisen, P. W.</author><author>Klok, F. A.</author><author>Huisman, M. V.</author></authors></contributors><auth-address>Department of Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, The Netherlands. p.l.den_exter@lumc.nl</auth-address><titles><title>Impact of delay in clinical presentation on the diagnostic management and prognosis of patients with suspected pulmonary embolism</title><secondary-title>Am J Respir Crit Care Med</secondary-title></titles><periodical><full-title>Am J Respir Crit Care Med</full-title></periodical><pages>1369-73</pages><volume>187</volume><number>12</number><edition>2013/04/18</edition><keywords><keyword>*Delayed Diagnosis</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Prognosis</keyword><keyword>Prospective Studies</keyword><keyword>Pulmonary Embolism/*diagnosis</keyword></keywords><dates><year>2013</year><pub-dates><date>Jun 15</date></pub-dates></dates><isbn>1535-4970 (Electronic)&#xD;1073-449X (Linking)</isbn><accession-num>23590273</accession-num><urls><related-urls><url>. Therefore, it is of great significance to improve the diagnosis rate of PE.Herein, we report the clinical history of an acute pulmonary embolism patient, whose ST-segment elevation in aVR lead and depression in other ten leads (besides V1 lead). Call on clinicians to increase their vigilance against PE, and emphasize the importance of ultrasonic cardiogram to assist in prompting PE.Case presentation A 69-year-old female patient presented with chest tightness and shortness of breath for three days, worsening for one day. Three days before onset, the patient developed chest tightness and shortness of breath during bathing and other activities, and these symptoms resolved in a few minutes after rest and failed to draw her attention. On the morning of her presentation to the Xiangya hospital, she suddenly felt chest tightness and shortness of breath worsening when she was hanging clothes after breakfast, with profusely sweating and palpitations, but no chest pain, no headache and dizziness. In the emergency department, the ECG showed that ST-segment elevation in aVR lead and depression in other ten leads (beside V1 lead) (Figure 1). Laboratory examination revealed myocardial injury biomarker cTnI was 0.31 ng/mL (normal range, <0.04 ng/mL). Based on her clinical symptoms and examination results, the clinicians suspected ACS. According to 2020 ESC guideline on selection of NSTEMI treatment strategy based on risk stratification, she classified as very high risk patient, CAG recommendation was class I and level C. So she received CAG, the result showed coronary atherosclerosis with slight stenosis. Therefore she transferred to cardiology department, with blood pressure 115/70 mmHg, pulse 113 times/min, breath rate 31 times/min.She was a non-smoker and teetotaler, doesn’t have previous history of similar episode. No previous history of coronary artery disease, peripheral vascular disease, stroke, malignancy, or venous thromboembolism was reported. And no family history of thromboembolic disease was reported. Her physical examination revealed an accentuated pulmonary component of the second heart sound and aortic systolic murmur. Laboratory findings showed the arterial blood gas test indicated 116 and 32 mmHg of PaO2 and PaCO2, respectively. Her ultrasonic cardiogram reported widened pulmonary arteries and elevated pulmonary artery pressure (SPAP 62mmHg). CT pulmonary angiography (CTPA) showed pulmonary artery and its branches have multiple filling defects, consider pulmonary embolism (Figure 2). Lung perfusion examination showed multiple lung perfusion function damage in both lungs. Color Doppler ultrasound results of lower limb blood vessels, abdomen and pelvis suggested no significant abnormalities.Based on the previous results, she was finally diagnosed as acute PE. According to 2014 European Society of Cardiology guideline, her pulmonary embolism severity index (PESI) score was 89 points, class III. Due to her RV function and laboratory testing were both positive, she received anticoagulation, monitoring and salvage reperfusion treatment. After noxaparin (6000u) treat for 5 days, her cardiac biomarkers was decreased and shortness of breath was significantly relieved. Then, enoxaparin was stopped, and dabigatran etexilate capsules (15mg) were taken orally for 3 days before discharged.Discussion and Conclusion Multi leads ST-segment elevate or depress is the common electric sign of ACS. Our patient presented chest tightness and shortness of breath after slight activity for three days, worsening for one day. Abnormal ECG changes and elevated cardiac biomarkers on admission led to a suspected diagnosis of ACS. However, urgent CAG didn’t support the aforementioned diagnosis. Both repeated ultrasonic cardiogram and CTPA confirmed widened pulmonary arteries and pulmonary embolism. She made an uneventful recovery under anticoagulation treatment for 5 days with cardiac biomarkers decreased and shortness of breath relieved. PE is a common clinical critical illness, but the diagnosis of PE is challenge due to atypical clinical symptoms and ECG presentation. The diagnosis of PE is based on the combination of symptoms, laboratory tests and radiological findings. ECG could facilitate to early diagnosis of PE. However, the ECG manifestations of PE are more complicated. 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ADDIN EN.CITE.DATA 10-12. Over the past 10 years, computed tomographic pulmonary angiography (CTPA) and percutaneous pulmonary angiography served as the main diagnostic tools of PE, and the timely detection and appropriate treatment for PE, such as thrombolysis and interventional therapy, could save the lives of patientsPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NZWluZWw8L0F1dGhvcj48WWVhcj4yMDE1PC9ZZWFyPjxS

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ADDIN EN.CITE.DATA 13-15. Due to the high cost and an invasive, although CPTA and percutaneous pulmonary angiography could significantly improve the diagnostic accuracy, it is not listed as the first choice for patients. Ultrasonic cardiogram can directly detect the right and left ventricular end-diastolic diameters of PE patients, and measure the pulmonary artery pressure, ventricular septum motion and peak velocity of blood reflux of tricuspid valve, and know whether the patients are complicated with right ventricular dysfunction. As one of the clinically important non-invasive examinations, ultrasonic cardiogram has important value in the prompt diagnosis of PE, prognostic evaluation and exclusion of other cardiovascular diseasesPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5LaGVtYXN1d2FuPC9BdXRob3I+PFllYXI+MjAxNTwvWWVh

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ADDIN EN.CITE.DATA 16. Therefore, the application of ultrasonic cardiogram in the auxiliary diagnosis of PE has great significance. In summarize, PE is characterized by a high incidence rate, high rates of missed diagnosis and misdiagnosis, and a high mortality rate. Therefore, clinicians need to have a high degree of suspicion for PE in patients presenting with potential cardiopulmonary symptoms, and use ultrasonic cardiogram for early diagnosis, since the consequences of missing or delaying the diagnosis of PE could be fatal.Reference ADDIN EN.REFLIST 1Howard, L. Acute pulmonary embolism. Clin Med (Lond) 19, 243-247, doi:10.7861/clinmedicine.19-3-247 (2019).2Meyer, G. et al. Fibrinolysis for patients with intermediate-risk pulmonary embolism. N Engl J Med 370, 1402-1411, doi:10.1056/NEJMoa1302097 (2014).3Marti, C. et al. Systemic thrombolytic therapy for acute pulmonary embolism: a systematic review and meta-analysis. Eur Heart J 36, 605-614, doi:10.1093/eurheartj/ehu218 (2015).4Han, Y. & Gong, Y. Pulmonary embolism with abdominal pain as the chief complaint: A case report and literature review. Medicine (Baltimore) 98, e17791, doi:10.1097/MD.0000000000017791 (2019).5Zelfani, S. et al. Pulmonary embolism mimicking acute myocardial infarction: a case report and review of literature. Pan Afr Med J 33, 275, doi:10.11604/pamj.2019.33.275.18517 (2019).6Bajaj, A. et al. Prognostic Value of Biomarkers in Acute Non-massive Pulmonary Embolism: A Systematic Review and Meta-analysis. Lung 193, 639-651, doi:10.1007/s00408-015-9752-4 (2015).7Pontana, F. et al. Impact of iterative reconstruction on the diagnosis of acute pulmonary embolism (PE) on reduced-dose chest CT angiograms. European radiology 25, 1182-1189, doi:10.1007/s00330-014-3393-5 (2015).8Ende-Verhaar, Y. M. et al. Incidence of chronic thromboembolic pulmonary hypertension after acute pulmonary embolism: a contemporary view of the published literature. Eur Respir J 49, doi:10.1183/13993003.01792-2016 (2017).9den Exter, P. L. et al. Impact of delay in clinical presentation on the diagnostic management and prognosis of patients with suspected pulmonary embolism. Am J Respir Crit Care Med 187, 1369-1373, doi:10.1164/rccm.201212-2219OC (2013).10Ullman, E., Brady, W. J., Perron, A. D., Chan, T. & Mattu, A. Electrocardiographic manifestations of pulmonary embolism. Am J Emerg Med 19, 514-519, doi:10.1053/ajem.2001.27172 (2001).11Thomson, D. et al. ECG in suspected pulmonary embolism. Postgrad Med J 95, 12-17, doi:10.1136/postgradmedj-2018-136178 (2019).12Zhang, J. et al. The electrocardiographic characteristics of an acute embolism in the pulmonary trunk and the main pulmonary arteries. Am J Emerg Med 34, 212-217, doi:10.1016/j.ajem.2015.10.028 (2016).13Meinel, F. G. et al. Predictive Value of Computed Tomography in Acute Pulmonary Embolism: Systematic Review and Meta-analysis. Am J Med 128, 747-759 e742, doi:10.1016/j.amjmed.2015.01.023 (2015).14Celik, A. et al. Usefulness of admission hematologic parameters as diagnostic tools in acute pulmonary embolism. Kaohsiung J Med Sci 31, 145-149, doi:10.1016/j.kjms.2014.12.004 (2015).15Jimenez, D. et al. Trends in the Management and Outcomes of Acute Pulmonary Embolism: Analysis From the RIETE Registry. J Am Coll Cardiol 67, 162-170, doi:10.1016/j.jacc.2015.10.060 (2016).16Khemasuwan, D. et al. Right ventricular echocardiographic parameters are associated with mortality after acute pulmonary embolism. J Am Soc Echocardiogr 28, 355-362, doi:10.1016/j.echo.2014.11.012 (2015).AcknowledgementsWe thanked the patient in this study.Conflict of interestThe authors declare no potential conflict of interests.Figure legendsFigure 1: Electrocardiogram shows ST-segment elevation in aVR lead and depression in other ten leads (besides V1 lead).Figure 2: CT pulmonary angiography (CTPA) showed pulmonary artery and its branches have multiple filling defects, consider pulmonary embolism. ................
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