From the Guidelines
Pulmonary embolism (PE) typically presents with symptoms such as unexplained shortness of breath, chest pain, tachycardia, apprehension or tachypnea, syncope, and hypoxemia, which require immediate medical attention. The most common symptoms of PE include dyspnea, pain, and tachypnea, which were present in 85%, 40%, and 29% of patients with PE, respectively, as reported in the prospective multicenter MASTER registry 1. Other symptoms may include coughing up blood, excessive sweating, anxiety or sense of impending doom, and leg pain or swelling (typically in the calf) if the clot originated in the leg.
Common Symptoms of PE
- Dyspnea (82%)
- Chest pain (49%)
- Cough (20%)
- Syncope (14%)
- Hemoptysis (7%)
These symptoms occur because a blood clot lodges in an artery in the lung, blocking blood flow and decreasing oxygen levels in the blood. Risk factors include prolonged immobility, recent surgery, cancer, pregnancy, and certain medications like birth control pills. The severity of symptoms often correlates with the size of the embolism and how much of the lung's blood supply is blocked. According to the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Cancer-Associated Venous Thromboembolic Disease, Version 2.2024, signs or symptoms of PE may also include unexplained shortness of breath, chest pain—particularly pleuritic chest or back pain—tachycardia, apprehension or tachypnea, syncope, and hypoxemia 1.
Diagnosis and Management
The preferred imaging technique for the initial diagnosis of PE is CT angiography (CTA), which allows for indirect evaluation of pulmonary vessels 1. CTA has several advantages, including accurate imaging of mediastinal and parenchymal structures, accurate visualization of emboli in many regions of the pulmonary vasculature, and the ability to detect signs of right ventricular (RV) enlargement, which can be used in assessing risk for adverse clinical outcomes. However, CTA also has disadvantages, such as associated radiation exposure and the need for large amounts of intravenous contrast. Alternative imaging modalities used for the diagnosis of PE include X-ray pulmonary angiography with contrast, MR angiography with contrast, and ventilation-perfusion (VQ) scan if CTA is contraindicated 1.
Anyone experiencing symptoms of PE, particularly sudden shortness of breath and chest pain, should seek emergency medical care immediately as PE can be life-threatening if not treated promptly. Early initiation of anticoagulation should be considered while waiting for imaging results in cases with a high suspicion of PE and no contraindications 1.
From the Research
Symptoms of Pulmonary Embolism
The symptoms of pulmonary embolism (PE) can vary, but common presentations include:
- Acute chest pain
- Shortness of breath
- Syncope These symptoms can be indicative of a blockage in a pulmonary artery, typically caused by a thrombus that travels from a vein in a lower limb 2.
Diagnosis and Evaluation
To evaluate a patient with possible PE, the following steps can be taken:
- Assessment of the clinical probability of PE
- D-dimer testing if indicated
- Chest imaging if indicated The clinical probability of PE can be assessed using a structured score or clinical gestalt, and patients with a low probability of PE may not require further testing 2.
Treatment Options
Treatment options for PE include:
- Anticoagulation therapy, such as unfractionated heparin, low molecular weight heparin (LMWH), or direct oral anticoagulants (DOACs)
- Thrombolysis for patients with systolic blood pressure lower than 90 mm Hg
- Surgical embolectomy or catheter-based embolectomy in selected cases DOACs, such as apixaban, edoxaban, rivaroxaban, or dabigatran, are noninferior to traditional anticoagulation therapy and have a lower rate of bleeding 2. LMWHs have a more predictable pharmacodynamic and pharmacokinetic profile compared to unfractionated heparin, and are often used as an alternative 3, 4, 5.
Management of Anticoagulation
The management of anticoagulation in PE can be complex, and suboptimal management of unfractionated heparin has been reported 6. LMWHs and DOACs can simplify the management of anticoagulation, but unfractionated heparin may still be used in certain cases 5. The choice of anticoagulant depends on various factors, including the patient's clinical presentation, renal function, and bleeding risk 3, 4, 5.