What are the symptoms and treatment of pulmonary embolism?

Symptoms of Pulmonary Embolism

The most common symptoms of pulmonary embolism are dyspnea (80%), pleuritic chest pain (52%), cough (20%), and syncope (19%), with clinical presentation varying based on the location and extent of the embolism. 1

Common Clinical Presentations

• Dyspnea (shortness of breath) is the most frequent symptom, present in approximately 80% of patients, and can be acute and severe in central PE or mild and transient in small peripheral PE 1, 2
• Pleuritic chest pain occurs in 52% of cases, typically caused by pleural irritation due to distal emboli causing pulmonary infarction 1, 3
• Substernal chest pain (12% of cases) may have angina-like characteristics, possibly reflecting right ventricular ischemia 1, 3
• Syncope occurs in 19% of cases and may present even without hemodynamic instability 1, 2
• Hemoptysis is present in 11% of cases, resulting from alveolar hemorrhage caused by small distal emboli 1, 3
• Cough is present in 20% of cases 1
• Tachypnea (respiratory rate >20/min) is found in 70% of patients 1
• Tachycardia (heart rate >100/min) occurs 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 occurs in 11% of cases 1

Presentation Based on PE Location

Central Pulmonary Embolism

• Presents with acute and severe dyspnea 1, 3
• May cause substernal chest pain with anginal characteristics 1
• Higher probability of hemodynamic instability 1, 2
• More frequent syncope 1
• May present with shock or persistent arterial hypotension in severe cases 3

Peripheral Pulmonary Embolism

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

Physical and Laboratory Findings

• Hypoxemia is present in 75% of cases, although up to 20% of patients may have normal arterial oxygen pressure 1, 2
• Hypocapnia is often present 1
• ECG may show signs of right ventricular overload in 50% of cases 1
• S1Q3T3 pattern (S wave in lead I, Q wave and inverted T wave in lead III) may be present 1
• T wave inversions in leads V1-V4 may be seen 1
• QR pattern in V1 and right bundle branch block (complete or incomplete) may be present 1

Special Considerations

• In patients with pre-existing heart failure or pulmonary disease, worsening dyspnea may be the only symptom indicative of PE 1, 3
• PE can be completely asymptomatic and discovered incidentally during diagnostic studies for other conditions 1, 2
• Approximately 40% of patients with PE do not have predisposing factors 1, 2

Risk Stratification

• High-risk PE is defined by hemodynamic instability (persistent arterial hypotension and/or shock), indicating high risk of early mortality 1, 3
• Non-high-risk PE requires additional evaluation to determine level of risk and guide management decisions 1, 2

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, 2
• Do not dismiss transient symptoms, as they can lead to delayed diagnosis or misdiagnosis 1
• Do not overlook PE in patients with pre-existing cardiopulmonary disease where worsening dyspnea may be the only new symptom 1, 3
• Do not rely solely on individual clinical signs or symptoms, as they lack specificity 1

Treatment of Pulmonary Embolism

• Anticoagulation is the mainstay of treatment for objectively confirmed PE, with a minimum duration of three months 4
• Direct oral anticoagulants (DOACs) like rivaroxaban are now preferred for most patients with PE 5
• Rivaroxaban is FDA-approved for the treatment of pulmonary embolism 5
• Risk stratification should be performed to determine if advanced treatments like thrombolysis or embolectomy are needed in high-risk patients 6, 7
• Hemodynamic and respiratory support are critical components of management in severe PE with shock or cardiac arrest 6
• Indefinite anticoagulation may be considered in patients with unprovoked PE due to the heightened risk of recurrence after anticoagulation cessation 4