warfarin and Syncope

PE (pulmonary embolism) is a life-threatening complication rarely seen in the AIHA (autoimmune haemolytic anaemia) patients. Herein we reported a rare and serious AIHA-PE patient characterised by extensive peripheral pulmonary embolism on CTPA.. A 59-year-old woman presented to our ED (emergency department) complaining of acute chest pain and dyspnea. During her presentation in ED she experienced a sudden syncope and soon developed CA (cardiac arrest). Laboratory studies showed a increase of CK-MB,troponin T,myoglobin and D-dimer. Computed tomography pulmonary angiography (CTPA) showed no large central or segment pulmonary emboli but increased RV (right ventricle)size,enlarged main pulmonary artery and invisible peripheral pulmonary artery. She was diagnosed with acute PE and alteplase was delivered intravenously. After thrombolytic therapy she remained hypotension and developed worsening anaemia. Detailed examination for anaemia revealed AIHA. She was discharged in a stable condition after 5 weeks with methylprednisolone and warfarin. Hb, D-dimer and transthoracic echocardiography showed complete recovery at 3-months follow up.. PE attributed to AIHA is characterized by subsegment and distal pulmonary artery embolism which is easily neglected but always life-threatening. This case also highlights the PE as a secondary diagnosis should be evaluated comprehensively in order to identify the underlying pathogenesis.

Topics: Acute Disease; Anemia, Hemolytic, Autoimmune; Anticoagulants; Female; Fibrinolytic Agents; Glucocorticoids; Humans; Methylprednisolone; Middle Aged; Pulmonary Embolism; Shock, Cardiogenic; Syncope; Thrombolytic Therapy; Tissue Plasminogen Activator; Treatment Outcome; Warfarin

Topics: Accidental Falls; Aged; Anticoagulants; Atrial Fibrillation; Humans; Syncope; Warfarin

Temporary transvenous pacemaker implantation is an important and critical procedure for emergency physicians. Traditionally, temporary pacemakers are inserted by electrocardiography (ECG) guidance in the emergency department because fluoroscopy at the bedside in an unstable patient can be limited by time and equipment availability. However, in the presence of atrial septal defect, ventricular septal defect, and patent foramen ovale, the pacemaker lead can be implanted inadvertently into the left ventricle or directly into the coronary sinus instead of right ventricle. Regular pacemaker rhythm can be achieved despite inadvertent implantation of the pacemaker lead into the left ventricle, leading to ignorance of the possibility of lead malposition.. A 65-year-old female patient with hemodynamic instability and complete atrioventricular block underwent temporary pacemaker implantation via right jugular vein with ECG guidance at the emergency department. Approximately 12 h after implantation, it was noticed that the ECG revealed right bundle branch block (RBBB)-type paced QRS complexes. Diagnostic workup revealed that the lead was inadvertently located in the left ventricular apex. This case illustrates the importance of careful scrutiny of the 12-lead ECG and imaging clues in identifying lead malposition in the emergency department. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Because inadvertent left ventricle endocardial pacing carries a high risk for systemic embolization, it is important to determine whether an RBBB pattern induced by ventricular pacing is the result of a malpositioned lead or uncomplicated transvenous right ventricular pacing.

Topics: Aged; Anticoagulants; Antihypertensive Agents; Atrial Fibrillation; Cardiac Pacing, Artificial; Diagnosis, Differential; Electrocardiography; Electrodes, Implanted; Emergency Service, Hospital; Female; Heart Ventricles; Humans; Hypertension; Metoprolol; Syncope; Warfarin

Syncope is a complicated clinical condition involving various diseases. Syncope due to myxoma-like right atrial thrombus is rarely seen in patient without structural heart disease.. A 61-year-old ambulant old male visited our emergency department for sudden syncope.. After the exclusion of neurological and coronary diseases, a right atrial block mass with a stalk connected to the atrial septum was accidentally found by echocardiography. Pulmonary embolism was subsequently revealed by computed tomographic pulmonary angiography. Atrial myxoma was initially suspected and surgical removal was conducted. Surprisingly, histological examination showed that the pedicled block mass was actually thrombus.. The myxoma-like right atrial thrombus and the emboli in the bilateral pulmonary trunks were resected. This patient received anticoagulant treatment with warfarin for 6 months additionally.. The patient was successfully discharged and being continually followed.. This patient had a past medical history of right femoral neck fracture, which might be responsible for the formation of the myxoma-like right atrial thrombus. We should always consider echocardiography examination in syncope patient at risk of thrombus formation.

Topics: Anticoagulants; Cardiac Surgical Procedures; Computed Tomography Angiography; Diagnosis, Differential; Echocardiography; Femoral Neck Fractures; Heart Atria; Heart Diseases; Humans; Incidental Findings; Male; Middle Aged; Myxoma; Pulmonary Artery; Pulmonary Embolism; Syncope; Thrombosis; Treatment Outcome; Warfarin

An 85-year-old man with persistent atrial flutter (AFL) with slow ventricular rate of 44/min, causing fatigue and presyncope, was referred for urgent treatment. In spite of thromboembolic risk scale value 4, he had not been treated with anticoagulants because of high risk of bleeding. The decision was made to perform urgent catheter ablation to interrupt and cure AFL. Intracardiac echocardiography probe was placed in the pulmonary artery and visualized left atrial appendage free from thrombus with its proper function. Heparin was administered and AFL stopped during energy application. Intracardiac echocardiography showed immediate thrombus formation in left atrial appendage owing to complete atrial standstill and no retrograde conduction during hemodynamically effective escape nodal rhythm. This case report shows that in patients with sinus node disease effective ablation of AFL with escape rhythm without retrograde conduction to the atria may result in complete 'electrically induced' atrial standstill and immediate thrombus formation.

Topics: Aged, 80 and over; Anticoagulants; Atrial Flutter; Brugada Syndrome; Cardiac Conduction System Disease; Cardiomyopathies; Catheter Ablation; Echocardiography, Transesophageal; Fatigue; Genetic Diseases, Inborn; Heart Atria; Heart Block; Heart Ventricles; Heparin, Low-Molecular-Weight; Humans; Male; Syncope; Thrombosis; Warfarin

The patient presented with syncope, without chest pain and dyspnea. There was no peripheral edema or nervous system signs. The electrocardiogram (ECG) showed QT-interval prolongation with T-wave inversion in anterior and inferior leads. T-wave inversion in the right-sided precordial leads should prompt consideration of right ventricular overload. The patient underwent computed tomography of the chest that demonstrated pulmonary embolism. Ultrasonography of the veins of the lower limbs revealed an isolated calf vein thrombosis.

Topics: Aged; Anticoagulants; Electrocardiography; Female; Humans; Leg; Long QT Syndrome; Pulmonary Embolism; Syncope; Tomography, X-Ray Computed; Ultrasonography; Venous Thrombosis; Warfarin

A free-floating thrombus in the left atrium is very rare in mitral stenosis. Such a thrombus can lead to sudden circulatory arrest and syncope or can cause severe cerebral or peripheral thromboembolic events. Clinical diagnosis is difficult, but left atrial thrombus should be suspected if patients with mitral stenosis and atrial fibrillation have intermittent or changing murmurs, emboli, or syncope. We describe the case of a patient with mild mitral stenosis under warfarin therapy, and a left atrial pedunculated thrombus discovered during the investigation for syncope attacks.

Topics: Aged; Anticoagulants; Atrial Fibrillation; Coronary Thrombosis; Diagnosis, Differential; Echocardiography, Transesophageal; Female; Heart Atria; Humans; Mitral Valve Stenosis; Syncope; Warfarin

Previous studies on the association between the distribution of left ventricle hypertrophy and the clinical features of hypertrophic cardiomyopathy (HCM) have yielded unclear results. The aim of this study was to investigate the differences in the prevalence, clinical features, management strategies, and long-term outcomes between patients with midventricular hypertrophic obstructive cardiomyopathy (MVHOCM) and patients with apical HCM (ApHCM).. A retrospective study of 60 patients with MVHOCM and 263 patients with ApHCM identified in a consecutive single-centre cohort consisting of 2068 patients with HCM was performed. The prevalence, clinical features, and natural history of the patients in these 2 groups were compared.. Compared with ApHCM patients, patients with MVHOCM tended to be much younger and more symptomatic during their initial evaluation. Over a mean follow-up of 7 years, the probability of cardiovascular mortality and that of morbidity was significantly greater in MVHOCM patients compared with ApHCM patients (log-rank, P < 0.001).. Our results suggest that, compared with ApHCM, MVHOCM represents an uncommon presentation of the clinical spectrum of HCM that is characterized by progressive clinical deterioration leading to increased cardiovascular mortality and morbidity. Our results also underscore the importance of the timely recognition of MVHOCM for the prediction of prognosis and the early consideration of appropriate management strategies.

Topics: Ablation Techniques; Adrenergic beta-Antagonists; Adult; Age Factors; Anticoagulants; Calcium Channel Blockers; Cardiomyopathy, Hypertrophic; Cohort Studies; Echocardiography; Echocardiography, Doppler, Color; Female; Follow-Up Studies; Heart Ventricles; Humans; Hypertrophy, Left Ventricular; Magnetic Resonance Imaging, Cine; Male; Middle Aged; Pacemaker, Artificial; Phenotype; Retrospective Studies; Syncope; Tachycardia, Ventricular; Thrombosis; Warfarin

Topics: Aged; Aged, 80 and over; Anticoagulants; Australia; Chest Pain; Female; Heart Diseases; Hospital Mortality; Humans; Hypoxia; Male; Neoplasms; Neurodegenerative Diseases; Nursing Homes; Pulmonary Embolism; Retrospective Studies; Sex Distribution; Syncope; Warfarin

We report the first case of acute subdural hematoma (SDH) developing after tightening the halo of an osteoporotic 61-year-old woman on warfarin therapy for bilateral traumatic vertebral artery dissection. We discuss literature relevant to this case with an emphasis on identifying warning signs, including recurrent pin loosening, especially in patients with compromised bone structure and high risk of bleeding. Our 61-year-old patient presented to neurosurgery clinic for a 2-month follow-up of a type-III odontoid fracture sustained in a motor vehicle accident. The patient had repeatedly loosened halo pins, and shortly after the pins were tightened, the patient had a syncopal event and struck her head. An emergent computed tomography scan revealed acute SDH requiring emergent craniotomy and evacuation. SDH following pin penetration in a patient with bilateral vertebral artery dissection, osteoporosis, and anticoagulation has not been reported as a complication of the use of the halo vest for stabilization of the cervical spine. The risk of this serious complication can be minimized by giving special consideration to patients with comorbidities and by repositioning problematic pins. This case demonstrates the importance of special attention to bone strength, bleeding risk, and recurrent minor complaints with use of the halo vest.

Topics: Accidental Falls; Accidents, Traffic; Anticoagulants; Bone Nails; Craniocerebral Trauma; Craniotomy; Device Removal; Equipment Failure; Female; Hematoma, Subdural, Acute; Hemorrhagic Disorders; Humans; Immobilization; Middle Aged; Odontoid Process; Osteoporosis, Postmenopausal; Risk Factors; Spinal Fractures; Syncope; Tomography, X-Ray Computed; Vertebral Artery Dissection; Warfarin

Topics: Accidental Falls; Anticoagulants; Emergency Medical Services; Emergency Treatment; Humans; Narration; Nose; Nursing Staff; Parents; Physicians; Shock, Hemorrhagic; Syncope; Warfarin; Workforce

Topics: Cardiac Catheterization; Child; Child, Preschool; Diagnosis, Differential; Diltiazem; Echocardiography; Humans; Hypokalemia; Male; Oxygen; Paralyses, Familial Periodic; Potassium; Seizures; Syncope; Tricuspid Valve Insufficiency; Tuberous Sclerosis; Warfarin

Topics: Alprostadil; Captopril; Cardiac Catheterization; Drug Therapy, Combination; Female; Humans; Middle Aged; Pulmonary Embolism; Recurrence; Syncope; Thrombolytic Therapy; Warfarin

Pulmonary embolism remains a frequent and often fatal disorder. For the majority of patients, anticoagulation with heparin followed by warfarin represents the primary mode of treatment. Thrombolytic therapy is recommended for the patient with massive pulmonary embolism that has produced hypotension. Embolectomy is reserved for the patient with post embolic systemic hypotension who has an absolute contraindication to thrombolysis or who deteriorates despite thrombolytic therapy. Following successful embolectomy the surgeon must treat the complications of the surgery and prevent recurrence. Complications include cerebral infarction, pulmonary infarction and endobronchial hemorrhage, right ventricular failure, local or systemic bleeding and venous stasis. A case of successful pulmonary embolectomy with a complicated postoperative course is presented and the pathophysiology and treatment of the complications are discussed.

Topics: Adrenal Gland Diseases; Chest Pain; Dyspnea; Female; Heparin; Humans; Hypotension; Middle Aged; Pain; Postoperative Complications; Pulmonary Embolism; Syncope; Warfarin

Topics: Angiography; Catheterization; Dyspnea; Hemoptysis; Heparin; Humans; Leg; Pain; Phlebography; Pulmonary Artery; Pulmonary Embolism; Radionuclide Imaging; Serum Albumin, Radio-Iodinated; Syncope; Technetium; Warfarin