Acute Pulmonary Embolism Presenting as Pulmonary Hemorrhage/Infarction Syndrome in the Elderly

PURPOSE: The purpose of this investigation was to determine the characteristics of the history, physical examination, chest radiograph, electrocardiogram, and the ventilation/perfusion lung scan probability in elderly patients with pulmonary embolism who present with the syndrome of pulmonary infarction or hemorrhage. BACKGROUND: In considering a possible diagnosis of acute pulmonary embolism, it is helpful to focus on the characteristics of the patient in terms of the characteristics of the presenting syndrome. The syndrome of pulmonary hemorrhage or pulmonary infarction is the most common syndrome of acute pulmonary embolism. It is defined by the presence of pleuritic pain or hemoptysis. Whether there are features of the pulmonary hemorrhage/infarction syndrome that are specific to elderly patients, or would suggest or tend to exclude a diagnosis is unknown. Therefore, this investigation was undertaken. METHODS: Patients reported in this investigation participated in the national collaborative trial of the Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED). All had pulmonary embolism diagnosed by pulmonary angiography. Patients with associated cardiac pulmonary disease were excluded. Elderly patients (N equals 17) were defined as patients at or above 70 years of age. Comparisons were made with patients age 40-69 years (N equals 67) and with patients under 40 years of age (N equals 35). RESULTS: In elderly patients, malignancy was a frequent predisposing factor (29%) in addition to immobilization (76%). Dyspnea or tachypnea, in addition to pleuritic pain or hemoptysis, were present in 94% of elderly patients. Among elderly patients with the pulmonary hemorrhage/infarction syndrome, pleuritic pain was more frequent than hemoptysis (88% vs. 12%). The electrocardiogram was normal in 62% of elderly patients. If abnormal, the most frequent abnormalities were nonspecific ST segment or T-wave changes (38%). The chest radiograph showed atelectasis or a pulmonary parenchymal abnormality in 82% of elderly patients. The central pulmonary artery dilated in 29% of elderly patients. A normal chest radiograph was uncommon, occurring in only 6%. The ventilation/perfusion lung scan was useful and was interpreted as high probability for pulmonary embolism in 41% of elderly patients. Elderly patients had a higher pulmonary artery mean pressure (25 Â+/-9 vs. 17 Â+/-7 mm Hg) and lower partial pressure of oxygen in arterial blood (64 Â+/-10 vs. 81 Â+/-14 mm Hg) than patients less than 40 years, and elderly patients tended to have more mismatched segmental perfusion defects on the ventilation/perfusion lung than patients less than 40 years (4.8 Â+/-5.5 vs. 2.1 Â+/-2.9 mismatched perfusion defects). CONCLUSIONS: Although a few clinical features of the pulmonary hemorrhage/infarction syndrome of pulmonary embolism in elderly patients differ from patients less than 40 years of age, in general, the clinical characteristics are comparable to younger patients.