Written by Clay Smith
Syncope or pre-syncope in patients with PE was associated with an increased risk for 30-day mortality (43% vs 6%) and was an independent predictor of 30-day mortality when accompanied by hemodynamic instability on admission. Don't try to treat them as an outpatient.
Why does this matter?
We recently learned that patients presenting with syncope had an unexpectedly high rate of concomitant PE in the PESIT study. Subsequent lower quality studies have raised concern about whether or not this is true. This study took a different approach: in patients with known PE who had pre-syncope or syncope as part of their presentation, did this portend a bad outcome?
DFO ("done fell out") a bad sign in PE
This was a secondary analysis of the prospective Italian Pulmonary Embolism Registry (IPER). The original study enrolled 1716 patients, 458 (26.6%) of whom had pre-syncope or syncope. Patients with syncope or pre-syncope had much higher 30-day mortality, 42.5% vs 6.2%. There was a suggestion that pre-syncope was actually worse than syncope, but I am not sure about this. Both were bad prognosticators. Pre-syncope was also an independent risk factor for mortality at 30 days in patients with hemodynamic instability at admission (hazard ratio 2.13). This was independent of RV dysfunction, age, or receipt of thrombolysis. What this means for us is that patients with PE plus syncope or pre-syncope are not good candidates for outpatient management and with high short-term mortality risk, some may benefit from ICU-level care.
Impact of syncope and pre-syncope on short-term mortality in patients with acute pulmonary embolism. Eur J Intern Med. 2018 Apr 11. pii: S0953-6205(18)30141-9. doi: 10.1016/j.ejim.2018.04.004. [Epub ahead of print]
Reviewed by Thomas Davis