From the Guidelines
Pleuritic chest pain in pulmonary embolism (PE) is primarily caused by inflammation of the pleura when a blood clot lodges in a pulmonary artery and creates an area of lung infarction, as stated in the most recent guideline by the British Thoracic Society 1. This occurs when the embolus is located peripherally enough to cause ischemia and necrosis of lung tissue adjacent to the pleural surface. The resulting inflammatory response irritates the highly innervated pleural membranes, producing the characteristic sharp, stabbing pain that worsens with breathing, coughing, or movement. Not all PE patients experience pleuritic pain; it's more common when emboli affect distal vessels rather than central pulmonary arteries. The pain typically localizes to the affected area and may be accompanied by a pleural friction rub on examination. Other symptoms of PE often include:
- Dyspnea
- Tachypnea
- Tachycardia
- Hypoxemia Recognizing pleuritic chest pain as a potential sign of PE is crucial for prompt diagnosis, as immediate anticoagulation therapy is essential to prevent further clot formation and reduce mortality risk, as emphasized in the European Heart Journal guidelines 1 and the British Thoracic Society guideline 1. The diagnosis of PE should be based on a combination of clinical assessment, laboratory tests, and imaging studies, as recommended by the European Society of Cardiology 1. In patients with suspected PE, a thorough evaluation of clinical presentation, medical history, and risk factors is essential to determine the likelihood of PE, as stated in the Annals of Emergency Medicine policy 1. The use of clinical prediction rules, such as the Wells score, and d-dimer testing can help identify patients at low risk of PE, who may be eligible for outpatient management, as suggested by the British Thoracic Society guideline 1. However, patients with high-risk PE or those with significant comorbidities should be managed in a hospital setting, with close monitoring and aggressive treatment, as recommended by the European Heart Journal guidelines 1. Overall, the management of PE requires a multidisciplinary approach, with consideration of individual patient factors, to optimize outcomes and reduce morbidity and mortality.
From the Research
Causes of Pleuritic Chest Pain in PE
Pleuritic chest pain in pulmonary embolism (PE) can be caused by several factors, including:
- Pleural effusion, which is a common complication of PE 2
- Infarction of the lung tissue, which can cause pain that is worsened by deep breathing or coughing
- Inflammation of the pleura, which can cause sharp, stabbing pain that is worsened by movement
Relationship between Pleural Effusion and PE
Pleural effusion is a significant predictor of PE, and the presence of pleuritic chest pain in a patient with a pleural effusion is highly suggestive of PE 2. Nearly all pleural effusions due to PE are exudates, frequently hemorrhagic, and with a marked mesothelial hyperplasia.
Diagnosis and Treatment
The treatment protocol for a patient with pleural effusion secondary to PE is the same as that for any patient with PE 2. Spiral computed tomography pulmonary angiography (CTPA) is the best way to evaluate the possibility of PE in a patient with a pleural effusion. Anticoagulant therapy is the mainstay of treatment for PE, and the presence of bloody pleural fluid is not a contraindication for the administration of anticoagulant therapy 2.
Anticoagulant Therapy
The choice of anticoagulant agent depends on several factors, including the patient's clinical status, renal function, and risk of bleeding 3, 4. Low molecular weight heparins (LMWHs) and direct oral anticoagulants (DOACs) are commonly used for the initial treatment of PE, while unfractionated heparin (UFH) may be used in certain situations, such as in patients with severe renal impairment or those who require close monitoring of their anticoagulant therapy 3, 4.