What are the signs of pulmonary thromboembolism (PTE)?

Signs and Symptoms of Pulmonary Thromboembolism (PTE)

The most common signs and symptoms of pulmonary thromboembolism (PTE) are dyspnea (present in 80-89% of cases), chest pain (40-60%), tachypnea (70%), syncope (14-19%), and hemoptysis (7-11%). 1, 2

Common Clinical Presentations

Symptoms

• Dyspnea:

  • Most common symptom (80-89% of cases)
  • Often of sudden onset
  • May be mild in peripheral PE or severe in central PE 2

• Chest Pain:

  • Present in 40-60% of cases
  • Two types:
    • Pleuritic (sharp, worsening with breathing) - more common
    • Substernal/angina-like (may reflect right ventricular ischemia in central PE) 1, 2

• Syncope:

  • Present in 14-19% of cases
  • Important warning sign indicating severely reduced hemodynamic reserve
  • Associated with higher prevalence of hemodynamic instability and right ventricular dysfunction 2

• Cough:

  • Present in 20-25% of cases 1

• Hemoptysis:

  • Present in only 7-11% of cases 1, 3

Signs

• Tachypnea (respiratory rate >20/min): Present in 70% of cases 1, 2
• Tachycardia (heart rate >100/min): Present in 26% of cases 1, 2
• Signs of DVT (unilateral leg swelling, pain): Present in 15% of cases 1
• Hypoxemia: Present in 75% of cases, though up to 40% may have normal arterial oxygen saturation 2
• Fever (>38.5°C): Present in 7% of cases 1
• Cyanosis: Present in 11% of cases 1
• Hypotension (systolic BP <90 mmHg or drop ≥40 mmHg lasting >15 minutes): Indicates high-risk PE 2

Clinical Probability Assessment

Clinical probability assessment is crucial for diagnostic approach. Two validated scoring systems include:

1. Wells Score: Categorizes patients into low, moderate, or high probability of PE 1
2. Revised Geneva Score: Based entirely on clinical variables 1

In both scoring systems:

• Low probability category: ~10% have PE
• Moderate probability category: ~30% have PE
• High probability category: ~65% have PE 1

Important Considerations

• Atypical presentations: Up to 1% of patients may have no symptoms before PE diagnosis 3
• High-risk indicators: Syncope, hypotension, and signs of right ventricular dysfunction indicate higher mortality risk 2
• Diagnostic pitfalls:
  • Normal arterial oxygen levels don't exclude PE (present in up to 20% of cases) 1
  • ECG changes (T wave inversion in leads V1-V4, S1Q3T3 pattern, right bundle branch block) may be present but are nonspecific 1
  • Chest X-ray findings are often nonspecific but useful for excluding other causes 1

Clinical Approach

When PE is suspected based on symptoms and signs:

1. Assess clinical probability using validated scoring systems
2. Consider D-dimer testing in low/intermediate probability cases
3. Proceed to appropriate imaging (CT pulmonary angiography is preferred) 2, 4

Early recognition of these signs and symptoms is critical as PE has a significant mortality rate (8-15% in the first 3 months) and prompt treatment improves outcomes 2.