Symptoms of Pulmonary Embolism
Dyspnea (shortness of breath) is the most common symptom of pulmonary embolism, occurring in approximately 80% of patients, followed by pleuritic chest pain in 52% of cases, and most patients will have tachypnea (respiratory rate >20/min) present in 70% of cases. 1, 2
Primary Clinical Presentations
The British Thoracic Society identifies three distinct clinical patterns that should raise suspicion for PE 3:
- Sudden collapse with raised jugular venous pressure (faintness and/or hypotension) 3
- Pulmonary hemorrhage syndrome (pleuritic pain and/or hemoptysis) 3
- Isolated dyspnea (breathlessness without cough, sputum, or chest pain) 3
Common Symptoms and Their Frequencies
Respiratory Symptoms
- Dyspnea occurs in approximately 80% of patients and can range from acute and severe in central PE to mild and transient in small peripheral PE 1, 2
- Tachypnea (respiratory rate >20/min) is present in 70% of cases 1, 4
- Cough occurs in 20-24% of patients 3, 1
- Hemoptysis is present in 11% of cases, resulting from alveolar hemorrhage caused by small distal emboli 1
Chest Pain Patterns
- Pleuritic chest pain occurs in 52% of cases, characterized by sharp, stabbing, or burning pain that intensifies with deep breathing, coughing, or respiratory movements 1, 5
- Substernal chest pain is present in 12% of cases and may represent right ventricular ischemia with anginal characteristics 1, 5
Cardiovascular Symptoms
- Syncope occurs in 19% of cases and may occur even without hemodynamic instability 1
- Tachycardia (heart rate >100/min) is present in 26% of cases 1
- Hypotension and shock are hallmarks of central PE with severe hemodynamic consequences 1
Physical Examination Findings
- Signs of deep vein thrombosis are present in only 15% of cases 1
- Fever (>38.5°C) occurs in 7% of cases 1, 4
- Cyanosis is present in 11% of cases 1
Symptom Patterns Based on PE Location
Central PE Characteristics
- Acute and severe dyspnea of rapid onset 1, 5
- Substernal chest pain with anginal characteristics 1, 5
- Higher probability of hemodynamic instability 1
- More frequent syncope 1
Peripheral PE Characteristics
- Mild and sometimes transient dyspnea 1, 5
- Pleuritic chest pain as the predominant feature 1, 5
- Hemoptysis from alveolar hemorrhage 1, 5
- Pleural effusion (usually mild) 1
Critical Clinical Pitfalls to Avoid
Do not rule out PE based on normal oxygen saturation alone, as up to 20% of patients may have normal arterial oxygen pressure despite having PE 1, 2. The European Society of Cardiology emphasizes that approximately 25% of PE patients do not have hypoxemia 1.
Do not dismiss the diagnosis in elderly patients or those with pre-existing cardiopulmonary disease, as PE is easily missed in these populations 3. In patients with pre-existing heart failure or pulmonary disease, worsening dyspnea may be the only symptom indicative of PE 1, 5.
Do not rely on individual clinical signs or symptoms for diagnosis, as they lack specificity and the predictive value of any single feature is less than 80% 5. However, the British Thoracic Society notes that the combination of tachypnea, pleuritic pain, and arterial hypoxemia strongly suggests PE, and the absence of all three virtually excludes the diagnosis 4.
Do not overlook PE in younger patients without obvious risk factors, though PE is rare if age <40 with no risk factors 3. Approximately 40% of patients with PE do not have predisposing factors 1.
Important Clinical Context
PE can be completely asymptomatic and discovered incidentally during diagnostic studies for other conditions 1. The clinical signs and symptoms of acute PE are highly non-specific and may be found in many other cardiac or pulmonary conditions 5.
Nearly half of PE patients (approximately 48%) do not have chest pain of any type, making isolated dyspnea a common presentation, particularly with central PE 5. The combination of dyspnea, tachypnea, or pleuritic pain is present in 97% of PE patients, with only 3% lacking all three features 5.