In pulmonary embolism, can dyspnea and chest pain be intermittent?

Symptom Patterns in Pulmonary Embolism

Yes, dyspnea and chest pain in pulmonary embolism can be intermittent, particularly in small peripheral PE where dyspnea is often mild and transient, though symptoms more commonly persist or progress depending on the location and extent of the embolus. 1

Symptom Variability Based on PE Location and Severity

Peripheral/Small PE

• Dyspnea in small peripheral PE is often mild and may be transient rather than progressive. 1
• Pleuritic chest pain from peripheral emboli occurs in approximately 52% of cases and is caused by pleural irritation from distal emboli causing alveolar hemorrhage. 2
• The sharp, stabbing pain intensifies with respiration, coughing, or deep breathing. 2, 3

Central PE

• Dyspnea in central PE is typically acute, severe, and of rapid onset rather than intermittent. 1
• Central PE more commonly presents with isolated dyspnea without chest pain. 2
• When pain occurs with central PE, it is substernal with anginal characteristics, possibly reflecting right ventricular ischemia. 1, 2

Critical Clinical Context

Approximately 48% of PE patients do not have chest pain of any type, and isolated dyspnea without pain occurs frequently, particularly with central PE. 2

Symptom Prevalence

• Dyspnea is present in 80% of PE cases, making it more common than chest pain. 2
• Tachypnea (respiratory rate >20/min) occurs in 70% of patients. 2
• The combination of dyspnea, tachypnea, or pleuritic pain is present in 97% of PE patients. 2

Worsening Symptoms in Pre-existing Disease

• In patients with pre-existing heart failure or pulmonary disease, worsening dyspnea may be the only symptom indicative of PE. 1
• This represents a change from baseline rather than new-onset symptoms, which can be subtle and intermittent. 1

Important Clinical Pitfalls

The European Respiratory Society advises against ruling out PE based on absence of pain, as nearly half of patients have no chest pain. 2

• Individual symptoms lack specificity, and the predictive value of any single feature is less than 80%. 2
• Up to 20% of PE patients have normal arterial oxygen pressure, so normal oxygenation does not exclude PE. 2
• The clinical signs and symptoms of acute PE are highly non-specific and may be found in many other cardiac or pulmonary conditions. 1

Progression Patterns

While symptoms can be intermittent in smaller PE, the absence of haemodynamic instability does not exclude beginning and possibly progressing right ventricular dysfunction. 1

• High-risk PE with haemodynamic instability indicates central or extensive PE with severely reduced haemodynamic reserve and represents an immediately life-threatening situation. 1
• Risk stratification is essentially based on the presence or absence of haemodynamic compromise (cardiogenic shock, hypotension) that may require supportive measures. 1