What are the characteristics of pain from pulmonary embolism (PE)?

Pain Characteristics in Pulmonary Embolism

Pain from pulmonary embolism most commonly presents as pleuritic chest pain (52% of cases), characterized by sharp, stabbing, or "knifelike" quality that worsens with deep breathing, coughing, or respiratory movements, though PE can also cause substernal angina-like chest pain (12% of cases) or present without pain at all. 1, 2

Primary Pain Patterns

Pleuritic Pain (Most Common)

• Sharp, stabbing, or burning pain that intensifies with respiration is the hallmark of PE-related pleuritic pain 1, 3
• Occurs in approximately 52% of PE patients and is typically localized to the affected area 1, 2
• Caused by pleural irritation from distal emboli leading to alveolar hemorrhage, often incorrectly termed "pulmonary infarction" 1, 3
• The pain is provoked or worsened by deep breathing, coughing, or other respiratory movements 3
• May be accompanied by pleural friction rub on examination, which sounds like creaking leather 3

Substernal Chest Pain (Less Common)

• Presents in approximately 12% of PE cases with an angina-like quality 1, 2
• Likely represents right ventricular ischemia from acute RV strain 1, 3
• More commonly associated with central PE causing significant hemodynamic consequences 1
• This central chest tightness may occur with circulatory collapse and hypotension in massive PE 1

Pain Patterns Based on PE Location

Peripheral/Distal PE

• Pleuritic chest pain is the predominant feature when emboli affect peripheral vessels 1, 3
• Associated with pleural irritation and alveolar hemorrhage 1, 3
• May present with hemoptysis (11% of cases) due to alveolar hemorrhage 1, 2
• Often accompanied by pleural effusion (46% of cases), which is frequently hemorrhagic 3

Central PE

• Isolated dyspnea of rapid onset is more typical than pleuritic pain 1
• When pain occurs, it is substernal with anginal characteristics 1, 3
• Associated with more prominent hemodynamic consequences including syncope (19% of cases) 1, 2
• May present with circulatory collapse, hypotension, and loss of consciousness 1

Critical Clinical Context

Pain Absence Does Not Exclude PE

• Approximately 48% of PE patients do not have chest pain of any type 1
• Isolated dyspnea without pain occurs frequently, particularly with central PE 1
• In patients with pre-existing heart failure or pulmonary disease, worsening dyspnea may be the only symptom 1, 2

Accompanying Features

• Dyspnea is present in 80% of PE cases, making it more common than pain 1, 2
• Tachypnea (respiratory rate >20/min) occurs in 70% of patients 1, 2
• The combination of dyspnea, tachypnea, or pleuritic pain is present in 97% of PE patients 1
• Only 3% of patients lack all three features (dyspnea, tachypnea, pleuritic pain), making their absence highly useful for excluding PE 1

Common Diagnostic Pitfalls

• Do not rule out PE based on absence of pain, as nearly half of patients have no chest pain 1
• Do not dismiss pain that is reproducible with palpation, as 7% of patients with reproducible chest wall tenderness have acute coronary syndrome, and PE can coexist 3
• Pleuritic pain has multiple causes including pneumonia, pneumothorax, and pericarditis, requiring further diagnostic evaluation 3
• Individual symptoms lack specificity—the predictive value of any single feature is less than 80% 1
• Up to 20% of PE patients have normal arterial oxygen pressure, so normal oxygenation does not exclude PE 1, 2