Is hypotension or hypertension expected in a patient with a pulmonary embolism (PE)?

From the Guidelines

Hypotension is more commonly expected in a patient with a significant pulmonary embolism (PE), particularly in cases of massive PE. When a large blood clot obstructs blood flow in the pulmonary arteries, it creates increased resistance in the pulmonary circulation. This obstruction leads to right ventricular strain and dysfunction as the right side of the heart struggles to pump blood against this increased resistance. As the right ventricle fails, cardiac output decreases, resulting in systemic hypotension. This hypotension can be severe and is associated with higher mortality rates, often indicating a massive PE that requires immediate intervention such as thrombolytic therapy 1. However, it's essential to note that many patients with smaller, submassive PEs may maintain normal blood pressure or even present with mild hypertension due to sympathetic nervous system activation from pain, anxiety, or hypoxemia. The presence of hypotension in PE is particularly concerning as it suggests right ventricular failure and hemodynamic compromise, requiring urgent assessment and management to prevent cardiovascular collapse.

Some key points to consider in the management of PE include:

• The use of systemically administered thrombolytic therapy in patients with acute PE associated with hypotension (eg, systolic BP < 90 mm Hg) who do not have a high bleeding risk 1
• The importance of anticoagulation in all patients with PE, with the choice of anticoagulant depending on the patient's risk factors and clinical presentation 1
• The need for close monitoring and prompt intervention in patients with high-risk PE, as these patients are at increased risk of mortality and morbidity 1

In terms of the expected blood pressure in a patient with PE, hypotension is a more concerning sign than hypertension, as it suggests right ventricular failure and hemodynamic compromise. However, both hypotension and hypertension can be seen in patients with PE, depending on the severity of the embolism and the patient's underlying clinical condition 1.

From the Research

Blood Pressure Expectations in Pulmonary Embolism (PE)

• Hypotension is expected in patients with massive pulmonary embolism, as it is associated with a poor prognosis and high mortality rates 2, 3.
• Patients with submassive PE may have normal blood pressure, but can still be at risk for cardiogenic shock 2.
• Thrombolytic therapy is generally indicated in patients with massive PE, particularly those with hypotension, as it can help to accelerate the lysis of the pulmonary embolism 4, 5, 6.
• In some cases, patients with PE may experience hypertension, but this is not typically expected in the acute phase of the condition 4.

Factors Influencing Blood Pressure in PE

• The size and location of the pulmonary embolism can affect blood pressure, with larger embolisms more likely to cause hypotension 3.
• The presence of right ventricular overload or dysfunction can also contribute to hypotension in patients with PE 4, 2.
• The use of thrombolytic therapy can help to improve blood pressure in patients with PE, but may also increase the risk of bleeding complications 4, 6.

Clinical Implications

• Patients with suspected PE should be closely monitored for signs of hypotension or hypertension, as these can be indicative of the severity of the condition 2, 3.
• Clinicians should consider the use of thrombolytic therapy in patients with massive PE, particularly those with hypotension, as it can help to improve outcomes 4, 5, 6.
• Further research is needed to fully understand the relationship between blood pressure and PE, and to determine the optimal treatment strategies for patients with this condition 2, 6.