From the Guidelines
Pulmonary embolism (PE) typically presents with sudden onset dyspnea, pleuritic chest pain, tachypnea, and tachycardia, and can be classified into two main groups: massive and non-massive, with the latter further subdivided into submassive and non-massive based on echocardiographic signs of right ventricular hypokinesis 1. The presentation of PE can vary in severity, with some patients experiencing cough, hemoptysis, syncope, and signs of deep vein thrombosis such as unilateral leg swelling, pain, or warmth. In severe cases, patients can present with hypotension, cyanosis, or even cardiac arrest.
Key Presentations
- Sudden onset dyspnea
- Pleuritic chest pain
- Tachypnea
- Tachycardia
- Cough
- Hemoptysis
- Syncope
- Signs of deep vein thrombosis Risk factors that should raise suspicion include recent surgery, prolonged immobilization, cancer, pregnancy, oral contraceptive use, and inherited thrombophilias.
Diagnostic Approach
Physical examination may reveal tachycardia, tachypnea, hypoxemia on pulse oximetry, decreased breath sounds, and a pleural friction rub. However, physical findings are often nonspecific, making diagnostic testing crucial. The Wells criteria or PERC rule can help stratify risk before proceeding to D-dimer testing, CT pulmonary angiography, or ventilation-perfusion scanning for definitive diagnosis, as recommended by the European Society of Cardiology 1.
Classification
The classification of PE into massive and non-massive is important for guiding treatment, with massive PE consisting of shock and/or hypotension, and non-massive PE further subdivided into submassive and non-massive based on echocardiographic signs of right ventricular hypokinesis 1.
Management
The management of PE depends on the severity of the presentation, with patients with high-risk PE requiring primary reperfusion treatment, particularly systemic thrombolysis, and intravenous UFH as the preferred mode of initial anticoagulation 1.
From the Research
Presentation of Pulmonary Embolism (PE)
The presentation of pulmonary embolism (PE) can vary, but common symptoms include:
- Sudden dyspnea 2, 3, 4, 5
- Chest pain, often pleuritic 2, 3, 4, 5
- Syncope 2, 3
- Hemoptysis 2, 3
- Limb swelling 3
- Shortness of breath 2, 4, 5
Clinical Evaluation
Clinical evaluation involves assessing symptoms, physical examination findings, and utilizing laboratory tests, including D-dimer 2, 3, 5. The clinical probability of PE can be assessed using a structured score or using clinical gestalt 2.
Risk Stratification
Risk stratification is critical to both the prognosis and management of acute PE 6, 3. Tools like Wells score, Pulmonary Embolism Severity Index, and Hestia criteria aid in determining the severity of PE 3. PE is categorized based on hemodynamic status, temporal patterns, and anatomic locations of emboli to guide in making treatment decisions 3.
Diagnostic Evaluation
Diagnostic evaluation involves chest imaging 2, and in some cases, D-dimer testing 2. In patients with a low or intermediate clinical probability, a D-dimer level of less than 500 ng/mL is associated with a posttest probability of PE less than 1.85% 2.
Atypical Presentations
Atypical presentations of PE can occur, especially in critically ill patients 4. Recognition of venous thromboembolic (VTE) risk factors can help develop a good clinical suspicion for PE 5.