Can symptoms of pulmonary embolism (PE) be transient?

Transient Symptoms in Pulmonary Embolism

Yes, symptoms of pulmonary embolism (PE) can be transient, with dyspnea being the most common symptom that may present as mild and temporary in small peripheral PE. 1

Clinical Presentation of PE with Transient Symptoms

• Dyspnea, the most frequent symptom (present in approximately 80% of PE cases), can be acute and severe in central PE or mild and transient in small peripheral PE 2, 1
• Pleuritic chest pain, present in about 52% of PE cases, can occur intermittently and is typically associated with peripheral emboli causing pleural irritation 2
• Syncope, though less common (19% of cases), can occur transiently even in patients without persistent hemodynamic instability 2, 1
• In patients with pre-existing heart failure or pulmonary disease, worsening dyspnea may be the only symptom indicative of PE, and this symptom may fluctuate 2

Pathophysiological Basis for Transient Symptoms

• Small peripheral emboli may cause temporary symptoms that resolve as the body's natural thrombolytic system begins to work on the clot 2
• Transient symptoms may occur when emboli partially obstruct pulmonary vessels temporarily before moving or dissolving 2
• The patency of the pulmonary arterial bed is restored in the majority of PE survivors within the first few months following the acute episode, which explains why symptoms may be temporary 2

Clinical Implications of Transient Symptoms

• Transient symptoms can lead to delayed diagnosis or misdiagnosis, as patients may not seek medical attention if symptoms resolve quickly 2
• Even with transient symptoms, untreated PE carries a high risk of recurrence, which can be fatal 2
• The European Society of Cardiology guidelines note that PE can present with a wide range of clinical presentations, from hemodynamic instability to silent or transient symptoms 2

Diagnostic Considerations with Transient Symptoms

• A high clinical suspicion for PE should be maintained even when symptoms are transient or have resolved at the time of evaluation 2
• Clinical decision rules to determine pre-test probability of PE should be applied regardless of whether symptoms are persistent or transient 2
• D-dimer testing and appropriate imaging should be considered even in patients with resolved symptoms if PE is clinically suspected 2

Management Implications

• Anticoagulation remains the mainstay of treatment for objectively confirmed PE, regardless of whether symptoms were transient or persistent 2, 3
• Duration of anticoagulation (minimum 3 months) should not be shortened based on resolution of symptoms 2
• Follow-up is recommended 3-6 months after acute PE, even if symptoms have resolved, to assess for chronic complications 2

Long-term Considerations

• Even after transient symptoms, patients may develop post-PE syndrome with decreased quality of life and/or chronic functional limitations 2
• Up to 47% of patients may have reduced maximal aerobic capacity at one year follow-up, regardless of whether initial symptoms were transient or persistent 2
• Persistent dyspnea or poor physical performance over several months after acute PE can occur even if the initial presentation included only transient symptoms 2