Bradyarrhythmia in acute massive pulmonary embolism

Pulmonary embolism (PE) can present with a variety of electrocardiographic findings. Bradycardia is a rare finding in acute PE, which typically manifests with sinus tachycardia. Bradycardia in acute PE might arise from the physiologic Bezold–Jarisch reflex, which describes the constellation of bradycardia, peripheral vasodilation, and hypotension. We report the case of a woman in her 60s who was admitted initially for submassive PE and found to have sinus bradycardia. She had progressed to massive PE with acute worsening of atrioventricular conduction block in the setting of atrial flutter. Her bradyarrhythmia resolved and hemodynamics improved after catheter directed thrombolysis. This case revisits the pathophysiology of Bezold–Jarisch reflex, and the importance of recognizing that it signifies an underlying pathologic insult, especially a life-threatening one like PE.