Echocardiography as a Useful Tool for Differentiating Acute Pulmonary Embolism From Acute Coronary Syndrome: A Case Report

Both acute coronary syndrome (ACS) and pulmonary embolism (PE) are life-threatening medical emergencies with overlapping symptoms and laboratory findings. Differentiating these two emergencies and initiating proper treatment are of paramount importance for good outcomes. In this report, we present the case of a 60-year-old male with a history of seizure disorder and hyperlipidemia, who presented to the emergency department (ED) after a syncopal episode preceded by three days of brief episodes of chest pain. In the ED, the initial electrocardiogram (EKG) showed normal sinus rhythm with T wave inversions in the anterior leads, and elevated high-sensitivity troponin levels peaked at 58 ng/mL before declining to 38 ng/mL. Elevated lactic acid and anion gap suggested a seizure, and the patient was discharged after lab tests and clinical status normalized. The patient returned the next day with recurrent syncope, and this time troponin levels were significantly elevated to 151 ng/mL, with a pro-BNP (brain natriuretic peptide) of 1,705 pg/mL. The patient was admitted with an initial diagnosis of ACS. The initial evaluation, including chest X-ray and EKG, was unremarkable. However, echocardiography revealed an interesting finding of right ventricular free wall akinesia with sparing of the apex-McConnell's sign-suggestive of PE, which significantly changed the diagnostic approach. PE was later confirmed by computed tomography angiography. This case highlights the critical role of echocardiography in distinguishing PE from ACS, especially in emergency care settings in patients with atypical and rare presentations.