Pulmonary embolism and pulmonary hypertension in the setting of negative computed tomography

Abstract

Introduction: Chronic pulmonary hypertension (PH) can display acute elevations in pulmonary arterial pressure (PAP) in the setting of hypoxemia, pulmonary embolism (PE), and possibly sepsis.Case Description: A 68-year-old man with chronic obstructive pulmonary disease, heart failure, recent tobacco cessation, and recent 2-vessel coronary artery bypass grafting (CABG) presented with one to two weeks of respiratory symptoms and syncope on the day of admission. He was found to have a urinary tract infection and Escherichia coli bacteremia. Transthoracic echocardiography found a systolic PAP of 100-105 mmHg, increased from a mean PAP of 32 mmHg before CABG. PE was not seen on computed tomography angiography (CTA). Ventilation-perfusion scan two days later found evidence of subsegmental PE. PAP prior to discharge was 30-35 mmHg plus right atrial pressure.Conclusion: PAP can rise substantially in the acute or subacute setting, particularly when multiple disease processes are involved, and decrease to (near) baseline with proper therapy. Chronic PH may even be protective. In a complex clinical setting with multiple possible etiologies for elevated PAP, clinicians should have a high suspicion for PE despite a negative CTA. AbbreviationList ADHF acute decompensated heart failure CABG coronary artery bypass grafting COPD chronic obstructive pulmonary disease CTA computed tomography angiography CXR conventional chest radiograph EF ejection fraction HCAP healthcare-associated pneumonia HFpEF heart failure with preserved ejection fraction INR international normalized ratio LV left ventricle Southwest Journal of Pulmonary and Critical Care/1016/Volume 12 116 PAP pulmonary arterial pressure PCWP pulmonary capillary wedge pressure PE pulmonary embolism PH pulmonary hypertension RA right atrium/atrial RV right ventricle/ventricular RHC right heart catheterization SaO2 arterial oxygen saturation TTE transthoracic echocardiography UTI urinary tract infection VTE venous thromboembolism VQ ventilation-perfusion