Pulmonary Embolism: Symptoms and Treatment
Pulmonary embolism (PE) presents most commonly with dyspnea (80-89%), chest pain (40-60%), tachypnea (70%), syncope (14-19%), and hemoptysis (7-11%), and requires prompt anticoagulation therapy with direct oral anticoagulants (DOACs) as first-line treatment for most patients. 1
Clinical Presentation
Common Symptoms
- Dyspnea: Most frequent symptom (80-89%), typically of sudden onset 1
- Chest pain: Present in 40-60% of cases, can be pleuritic or substernal/angina-like 1
- Syncope or fainting: Occurs in 14-19% of patients 1
- Hemoptysis: Present in 7-11% of cases 1
- Cough: Occurs in 20-25% of patients 1
Common Signs
- Tachypnea: Respiratory rate >20/min in 70% of cases 1
- Tachycardia: Heart rate >100/min in 26% of cases 1
- Signs of DVT: Present in 15% of patients 1
- Fever (>38.5°C): Present in 7% of cases 1
- Cyanosis: Present in 11% of cases 1
Risk Factors
- Recent surgery or trauma
- Malignancy
- Estrogen exposure
- Immobility
- Previous venous thromboembolism (VTE)
- Thrombophilia
Diagnostic Approach
Clinical Probability Assessment
- Use validated tools such as Wells Score or Revised Geneva Score to categorize patients into low, moderate, or high probability of PE 1
- Consider PE in patients with unexplained dyspnea (especially sudden onset), pleuritic chest pain, syncope without alternative explanation, or presence of VTE risk factors 1
Diagnostic Tests
- D-dimer: High sensitivity (90%) but low specificity (50%); useful for ruling out PE in low-risk patients 1
- CT Pulmonary Angiography (CTPA): First-line imaging test with high sensitivity (90%) and specificity (95%) 1
- Ventilation/Perfusion (V/Q) scan: Alternative when CTPA is contraindicated 1
- Echocardiography: Useful for risk stratification and when CTPA is unavailable in unstable patients 1
- Lower extremity ultrasound: Can identify DVT in patients with suspected PE 1
Treatment
Anticoagulation
Direct Oral Anticoagulants (DOACs): First-line therapy for most patients 2
- Rivaroxaban: Indicated for treatment of PE 2
- Initial dosing typically higher for first 21 days, followed by maintenance dosing
Low Molecular Weight Heparin (LMWH): Alternative to DOACs, especially in cancer patients 3
Unfractionated Heparin (UFH): Consider in patients with severe renal impairment or when rapid reversal may be needed 3
Vitamin K Antagonists (VKAs): When started, should be overlapped with parenteral anticoagulation for ≥5 days until INR is 2.0-3.0 for 2 consecutive days 3
Thrombolytic Therapy
Indicated for high-risk PE with hemodynamic instability 3
Options include:
Contraindications to thrombolysis include:
- Absolute: History of hemorrhagic stroke, ischemic stroke within 6 months, CNS neoplasm, recent major trauma/surgery/head injury, bleeding diathesis, active bleeding 3
- Relative: TIA within 6 months, oral anticoagulation, pregnancy, non-compressible puncture sites, traumatic resuscitation, refractory hypertension, advanced liver disease, infective endocarditis, active peptic ulcer 3
Duration of Anticoagulation
- Minimum 3 months for all patients with objectively confirmed PE 3, 2
- Consider extended/indefinite anticoagulation for:
- Unprovoked PE
- Recurrent VTE
- Active cancer
- Persistent risk factors
Follow-up and Complications
Follow-up Recommendations
- Routine clinical evaluation 3-6 months after acute PE episode 3, 1
- Assess for:
- Recurrent VTE symptoms
- Bleeding complications
- Persistent dyspnea or exercise limitation
- Signs of chronic thromboembolic pulmonary hypertension (CTEPH)
Potential Complications
- CTEPH: Occurs in 2-4% of PE survivors, potentially fatal if untreated 1
- Post-PE syndrome: Affects up to 47% of patients at 1-year follow-up with persistent dyspnea and exercise limitation 1
Special Considerations
- Pregnancy: LMWH preferred over DOACs or VKAs
- Cancer: Extended anticoagulation often required
- Renal impairment: Dose adjustment or alternative anticoagulants may be needed
- Elderly patients: Higher bleeding risk requires careful monitoring