Pulmonary Embolism as a Likely Diagnosis in This Clinical Context
Pulmonary embolism is a highly likely diagnosis in this older adult female with ovarian cancer awaiting surgery, and should be strongly considered as a potential cause of sudden death, particularly given that 59% of PE-related deaths remain undiagnosed during life and 34% present as sudden fatal PE. 1
Risk Factor Analysis
This patient presents with multiple established risk factors that substantially elevate PE probability:
Strong and Moderate Risk Factors Present
Active malignancy (ovarian cancer): Cancer increases the risk of PE four-fold compared to the general population, with ovarian cancer specifically associated with particularly high thrombotic risk 1. Ovarian carcinoma demonstrates a 44% incidence of pulmonary embolism in some series, with PE constituting a major cause of death in this population 2.
Advanced age: Patients older than 40 years have exponentially increased PE risk, with risk approximately doubling with each subsequent decade 1. Age over 40 is considered an independent risk factor 1.
Pre-operative status: The risk of VTE is highest during the perioperative period, though notably elevated even before surgery in cancer patients 3. Silent VTE occurs with high frequency before treatment in ovarian cancer patients, with studies showing 25% incidence of DVT and 11.1% incidence of PE detected before initial treatment 4.
Clinical Presentation Considerations
The sudden death presentation is particularly concerning for massive PE, as:
- Sudden death may be the first presentation of PE, with 34% of PE-related deaths presenting as sudden fatal events 1
- 59% of PE deaths remain undiagnosed during life, and only 7% of patients who died early were correctly diagnosed with PE before death 1
- More than 70% of major PEs are missed by clinicians even in autopsy studies 1
The fall and headache prior to death could represent:
- Syncope from massive PE causing hemodynamic compromise 1
- Cerebral hypoperfusion secondary to acute right ventricular failure
- A separate neurological event, though PE remains highly probable given the risk profile
Diagnostic Probability Assessment
Based on the clinical context, this patient would be classified as high probability for PE using established prediction rules:
- Multiple major risk factors (cancer, advanced age, pre-operative status) 1
- High-risk population with ovarian cancer demonstrating 25-44% incidence of VTE even before treatment 2, 4
- Sudden death presentation consistent with massive PE 1
Important Caveats
The majority of PE in cancer patients may be asymptomatic or present atypically 5, 4. The fall and headache may have been the only clinical manifestations before sudden cardiovascular collapse. In ovarian cancer specifically:
- 73% demonstrate episodic thrombocytosis related to tumor breakdown, strongly associated with PE risk 2
- Silent DVT occurs in 25% of patients before treatment, with 40-50% of proximal DVTs complicated by PE without clinical manifestations 1, 4
PE should be considered the primary diagnosis until proven otherwise in this clinical scenario, given the convergence of multiple high-risk factors, the known high incidence in ovarian cancer, and the typical presentation of sudden death in undiagnosed PE 1, 2.