Asymptomatic bradycardia as a manifestation of intermediate high-risk pulmonary embolism

Progressively worsening dyspnea as an initial manifestation of an intermediate high-risk pulmonary embolism (PE) is a readily reported life-threatening cardiac emergency. Atypical presentation of PE may make the initial diagnosis challenging and is often the reason it is missed by clinicians. A 60-year-old woman with asymptomatic bradycardia presented with shortness of breath and dizziness. On examination, she was noted to have a heart rate of 40 beats per minute (bpm) which slightly improved to 55 bpm after intravenous (IV) fluids were administered. A transthoracic echocardiogram (TTE) showed evidence of severe right ventricular strain. Chest computed tomography angiogram (CTA) confirmed PE. After percutaneous aspiration thrombectomy, she was transitioned to direct oral anticoagulant (DOAC) from a heparin infusion and discharged on oral anticoagulation. Notably, her hospital course was marked by labile cycles between normotension and hypertension, with blood pressures exceeding 200/100 mmHg. The possibility that hypertensive states may prevent hemodynamic deterioration and a resulting high-risk pulmonary embolism is considered in patients presenting with multiple risk factors for thromboembolism.