Episode 460 – RLR – Abrupt Lightheadedness
A 65-year-old man presents with abrupt lightheadedness during bike riding and walking, initially dismissed as mild dehydration or orthostasis. What appears to be a routine case of presyncope rapidly escalates when a subtle EKG change—T-wave inversions in V2–V3 with inferior lead involvement—triggers a critical diagnostic pivot. The host, Prof. Rez, reveals that the patient was discharged after a normal EKG and low troponin, only to return hours later with a witnessed syncopal episode, elevated troponin, and a massive pro-BNP of 6,000. A chest X-ray shows a widened mediastinum, prompting a CTA that reveals a life-threatening saddle pulmonary embolism with right heart strain. The real breakthrough comes when Robbie, the guest, identifies the EKG pattern not as a sign of acute coronary syndrome, but as a classic Wellens-like pattern strongly associated with pulmonary embolism—especially when combined with tachycardia, inferior changes, and an underwhelming troponin. The episode underscores a powerful lesson: subtle EKG patterns can be the first clue to massive PE, and clinicians must train their pattern recognition to catch these 'silent' red flags. The emotional core emerges in the aftermath: a tribute to a lost cat, a meditation on unconditional love, and the profound realization that medicine is not just about data, but about human connection.
A Wellens-like EKG pattern (T-wave inversions in V2–V3 with inferior lead involvement) is a red flag for pulmonary embolism, not just acute coronary syndrome.
An underwhelming troponin in a patient with lightheadedness and right heart strain should raise suspicion for PE, not ACS.
Sinus tachycardia combined with anterior and inferior EKG changes is a high-yield clue for pulmonary embolism.
Pulmonary embolism can cause syncope via the Beasold-Jerish reflex—a pathological vagal response—not just massive hemodynamic collapse.
Always get an EKG in exertion-dependent lightheadedness, but skip it in non-exertional disequilibrium.
…and 3 more takeaways available in PodZeus
Welcome Back & The Power of the RLR Community
The episode opens with a warm welcome and a plug for the RLR book, emphasizing the value of lifelong learning and community. The hosts reflect on the emotional depth of their connection, setting a tone of authenticity and shared purpose.
A Cat’s Legacy: Grief, Love, and the Meaning of Life
“I think the thing I want to carry with me for each of my interactions with anyone is that I did no harm. And I was like the best brother I could be, the best friend I could be, the best son I could be and realizing life is short and knowing that you were just a good person towards others gives so much comfort.”
The Case of Abrupt Lightheadedness: A Clinical Puzzle Begins
Prof. Rez presents a 65-year-old man with exertional lightheadedness, no cardiac symptoms, normal BP, and mild anemia. The patient is discharged after a normal EKG, but returns hours later with a witnessed syncopal episode.
The EKG That Changed Everything: Recognizing the Wellens Pattern
“The most alarming is the inferior leads 3 in AVF, very, very suggestive of the possibility of PE. Then if you look more closely, you'll see that the patient is tachycardic... sinus tachycardia plus these changes is another clue for PE.”
The CT Scan and the Realization: A Saddle Pulmonary Embolism
“He has basically saddle pulmonary embolism that bridges both the right and left main pulmonary trunks. I'm looking now to see what's happening. And unfortunately for him, his RV is way bigger than his LV2. He's got septal deviation to the left. So this is a very, very serious situation.”
“So he has basically saddle pulmonary embolism that bridges both the right and left main pulmonary trunks. I'm looking now to see what's happening. And unfortunately for him, his RV is way bigger than his LV2. He's got septal deviation to the left. So this is a very, very serious situation.”
“And then I think the most alarming is the inferior leads 3 in AVF, very, very suggestive of the possibility of PE. Then if you look more closely, you'll see that... The patient is tachycardic. I mean, this is sinus tachycardia and yeah, 300 -150, like basically borderline tachycardic.”
“So patients with PE syncopies, not because of anything else, but because of a pathological vagal response that they have. It's called the Beasold -Jerish reflex. It's a really good read.”
Host
Guest
Robbie
person
Prof. Rez
person
RLR
organization
Gino
person
Wellens pattern
other
saddle pulmonary embolism
other
CTA
other
chest x-ray
other
The Clinical Problem Solvers
organization
Beasold-Jerish reflex
other
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