What are the symptoms of a pulmonary embolism?

Symptoms of Pulmonary Embolism

The most common symptoms of pulmonary embolism include dyspnea (80%), pleuritic chest pain (52%), syncope (19%), and hemoptysis (11%), with physical findings of tachypnea (70%) and tachycardia (26%). 1

Common Clinical Presentations

• Dyspnea (shortness of breath) is the most frequent symptom, present in approximately 80% of patients with PE, and can be acute and severe in central PE or mild and transient in small peripheral PE 1
• Pleuritic chest pain occurs in 52% of cases, typically caused by pleural irritation due to distal emboli 1
• Substernal chest pain (angina-like) is present in 12% of cases and may represent right ventricular ischemia 1
• Syncope occurs in 19% of cases and may be present even without hemodynamic instability 1
• Hemoptysis is present in 11% of cases, resulting from alveolar hemorrhage caused by small distal emboli 1
• Cough is present in 20% of cases 1

Common Physical Findings

• Tachypnea (respiratory rate >20/min) is present in 70% of cases 1
• Tachycardia (heart rate >100/min) is present in 26% of cases 1
• Signs of deep vein thrombosis are present in 15% of cases 1
• Fever (>38.5°C) is present in 7% of cases 1
• Cyanosis is present in 11% of cases 1
• Hypotension and shock are hallmarks of central PE with severe hemodynamic consequences 1

Presentation Based on PE Location

Central Pulmonary Embolism

• Often presents with acute and severe dyspnea 1
• May present with substernal chest pain with anginal characteristics 1
• Higher probability of hemodynamic instability 1
• More frequent syncope 1
• Sudden collapse with raised jugular venous pressure may occur 2

Peripheral Pulmonary Embolism

• Often presents with mild and sometimes transient dyspnea 1, 3
• Commonly presents with pleuritic chest pain 1
• Associated with hemoptysis 1
• May present with pleural effusion (usually mild) 1

Important Clinical Considerations

• PE is easily missed in patients with severe cardiorespiratory disease, elderly patients, or if the only symptom is breathlessness ("isolated dyspnea") 2
• In patients with pre-existing heart failure or pulmonary disease, worsening dyspnea may be the only symptom indicative of PE 1
• Symptoms may be transient as small peripheral emboli can cause temporary symptoms that resolve as the body's natural thrombolytic system begins to work on the clot 3
• PE can be completely asymptomatic and discovered incidentally during diagnostic studies for other conditions 1
• Up to 20% of patients with PE may have normal arterial oxygen pressure and a normal alveolar-arterial oxygen gradient 2

Diagnostic Findings

• ECG signs of right ventricular strain may be present, including inversion of T waves in leads V1–V4, QR pattern in lead V1, S1Q3T3 pattern, and incomplete or complete right bundle-branch block 2, 1
• Chest X-ray findings may include atelectasis or infiltrate (49%), pleural effusion (46%), pleural-based opacity (23%), elevated diaphragm (36%), decreased pulmonary vascularity (36%), and amputation of hilar artery (36%) 1
• Hypoxemia is present in 75% of cases, although up to 20% of patients may have normal arterial oxygen pressure 1
• Hypocapnia is often present 1

Clinical Pitfalls to Avoid

• Do not rule out PE based on normal oxygen saturation, as up to 40% of patients may have normal arterial oxygen saturation 1
• Do not dismiss transient symptoms, as they can lead to delayed diagnosis or misdiagnosis 3
• Do not overlook PE in patients with pre-existing cardiopulmonary disease where worsening dyspnea may be the only new symptom 1
• Do not rely solely on individual clinical signs or symptoms, as they lack specificity 1
• Remember that PE is a potentially fatal disorder with a range of clinical presentations (from hemodynamic instability to silent) 2