[RIGHT HEART FAILURE PRESENTATION OF IDIOPATHIC MASSIVE PULMONARY EMBOLISM - CASE REPORT].

Abstract

Introduction: Massive pulmonary embolism (PE) is a life threatening condition with age-related escalation in prevalence. Acute PE is a common and sometimes fatal disease. The approach to the evaluation should be efficient while simultaneously avoiding the risks of unnecessary testing so that therapy can be promptly initiated and potential morbidity and mortality avoided. The imminent condition might lead to obstructive shock with acute right heart failure and eventually to rapid hemodynamic deterioration and death. At a younger age, massive PE causes death very rapidly in one third of the cases. During one year, follow-up of death in the presence of right heart failure is three times higher than those without it. About half of PE cases, are idiopathic and occur without acquired risk factors such as antecedent trauma, surgery, immobilization, or diagnosis of cancer. Unlike provoked PE (pPE) with acquired risk factors, idiopathic PE (iPE) is less likely to be predicted or prevented. Failure to accurately and promptly diagnose and treat deep vein thrombosis (DVT) and PE can result in excess morbidity and mortality due to post thrombotic syndrome, pulmonary hypertension, and recurrent thrombosis. Chest pain and shortness of breath are chief complaints frequently evaluated in the emergency department. Younger patients tend to have benign presentations, and often leave with diagnoses of self-limiting diseases or etiologies that are easily treated in the emergency department. The presenting clinical signs and symptoms should illuminate the primary physician to this life-threatening condition leading to fast diagnosis and prompt lifesaving treatment. At the end of the primary treatment, we need to assess and address each patient for the likelihood of thromboembolism recurrence, which will be highest among those patients with idiopathic events or those with cancer-associated thrombosis. We favor prolonged anticoagulation in these scenarios. In addition, we strongly advocate periodic scheduled follow-up of patients on long-term anticoagulation for secondary prophylaxis to re-evaluate their bleeding and recurrence risk. In practice, initial treatment of deep venous thrombosis and pulmonary embolism should be based on low molecular weight heparin (LMWH) in patients without renal failure. Thrombolytic agents may be useful in case of massive pulmonary embolism, but more evaluation is needed. Bleeding and heparin thrombocytopenia are the main adverse effects of these treatments.