From the Guidelines
Pulmonary embolism typically presents with sudden onset of shortness of breath, chest pain, and syncope, which are the most critical signs and symptoms to recognize for prompt medical attention. The clinical presentation of pulmonary embolism (PE) can vary widely, ranging from asymptomatic to life-threatening symptoms 1. Common symptoms include dyspnea, chest pain, and syncope, which occur in approximately 97% of patients with PE 1. Dyspnea is the most frequent symptom, often accompanied by chest pain that may worsen with deep breathing or coughing.
Key Symptoms
- Sudden onset of shortness of breath (dyspnea)
- Chest pain that may worsen with deep breathing or coughing
- Syncope (fainting)
- Tachycardia (rapid heart rate) and tachypnea (rapid breathing)
- Coughing up blood (hemoptysis) in less than a third of cases
- Anxiety, lightheadedness, sweating
Physical Examination Findings
- Hypoxemia (low oxygen levels)
- Cyanosis (bluish discoloration of the skin)
- Fever
- Signs of deep vein thrombosis like leg swelling or pain if the PE originated from a leg clot
- In massive PE, patients may develop hypotension, shock, and right heart failure with jugular venous distention
The symptoms of PE occur because the clot blocks blood flow in the pulmonary arteries, preventing normal oxygen exchange and increasing pressure in the right side of the heart 1. Recognizing these signs promptly is crucial as PE can be life-threatening and requires immediate medical attention for anticoagulation therapy or, in severe cases, thrombolysis or embolectomy. Echocardiography can be a valuable complementary imaging technique in the diagnosis of PE, especially in critically ill patients 1.
From the Research
Signs and Symptoms of Pulmonary Embolism
- Pulmonary embolism (PE) can present with a wide range of symptoms, from asymptomatic to cardiac arrest, making diagnosis challenging 2
- The symptoms of PE may be non-specific; diagnosis therefore relies on a clinical assessment and objective diagnostic testing 3
- A clinical decision rule can determine the pre-test probability of PE 3
Diagnosis of Pulmonary Embolism
- Computed tomographic pulmonary angiography appears to be the most useful study for diagnosis of PE in the critically ill 4
- Imaging with ventilation-perfusion (VQ) scan is associated with lower radiation exposure than computed tomography pulmonary angiogram, and may be preferred in younger patients and pregnancy 3
- A low probability or high probability VQ scan is helpful for ruling out or confirming PE, respectively; however, an intermediate probability VQ scan requires further investigation 3
Risk Stratification of Pulmonary Embolism
- Patients with PE can be stratified to four risk classes (high, intermediate-high, intermediate-low and low risk) using clinical, laboratory and imaging parameters 5
- The individual risk for PE-related complications and death increases with the number of comorbidities and severity of right ventricular dysfunction 5
- The presence of hypotension is the most significant predictor of poor outcome and defines those with massive PE 4
- Normotensive patients with evidence of right ventricular (RV) dysfunction, as assessed by echocardiography, comprise the sub-massive category and are at intermediate risk of poor outcomes 4
Treatment of Pulmonary Embolism
- The initial therapy for patients with PE is anticoagulation 4
- The recommended definitive treatment for patients with massive PE is thrombolysis (in addition to anticoagulation) 4
- Alteplase is a fibrinolytic that is indicated for the treatment of pulmonary embolism in intermediate- and high-risk patients 2
- The use of low molecular weight heparins (LMWHs) is recommended for PE patients with cancer; however, recent studies indicate that treatment with factor Xa-inhibitors may be effective and safe (in patients without gastrointestinal cancer) 5