What are the symptoms and treatment of pulmonary embolism?

Symptoms and Treatment of Pulmonary Embolism

Dyspnea (shortness of breath) is the most common symptom of pulmonary embolism, occurring in approximately 80% of patients, and can be acute and severe in central PE or mild and transient in small peripheral PE. 1

Common Clinical Presentations

• Dyspnea is present in approximately 80% of patients with pulmonary embolism 1
• Pleuritic chest pain occurs in 52% of cases, typically caused by pleural irritation due to distal emboli 1
• Substernal chest pain is present in 12% of cases, may represent right ventricular ischemia 1
• Syncope occurs in 19% of cases, may occur even without hemodynamic instability 1
• Hemoptysis is present in 11% of cases, results from alveolar hemorrhage caused by small distal emboli 1
• Cough is present in 20% of cases 1
• 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 PE

• 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

Peripheral PE

• Presents with mild and sometimes transient dyspnea 1
• May present with pleuritic chest pain 1
• Associated with hemoptysis 1
• May present with pleural effusion (usually mild) 1

Diagnostic Findings

• Hypoxemia is frequent, although up to 40% of patients may have normal arterial oxygen saturation 1, 2
• Hypocapnia is often present 1, 2
• Electrocardiogram may show 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
• Inversion of T waves in leads V1-V4 may be present 1
• QR pattern in V1 may be present 1
• 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, 2
• 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

Treatment of Pulmonary Embolism

Risk Stratification

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

Anticoagulation Therapy

• Anticoagulation is the foundation of treatment for most patients with PE 3
• Direct oral anticoagulants (DOACs) such as rivaroxaban are indicated for the treatment of pulmonary embolism 4
• Standard duration of anticoagulation is at least three months, but indefinite anticoagulation is being considered increasingly due to heightened risk for recurrence following anticoagulation cessation 5
• For rivaroxaban, the recommended dosage for treatment of PE is 15 mg twice daily with food for the first 21 days, followed by 20 mg once daily with food 4

Advanced Treatment Options

• Patients with high-risk PE (with hemodynamic instability) should be evaluated for advanced treatments such as thrombolysis or embolectomy 6, 3
• Hemodynamic support with fluid therapy, vasopressors, inotropes, or mechanical circulatory support may be necessary in severe cases 6
• Oxygen therapy and ventilation support may be required for respiratory compromise 6

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 1
• 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
• Do not delay diagnosis and treatment, as PE is the third most common cause of death from cardiovascular disease after heart attack and stroke 3