Pulmonary Embolism Clinical Presentation and Diagnosis

Common Clinical Presentations

• Dyspnea (shortness of breath) is present in approximately 80% of patients with pulmonary embolism, and can be acute and severe in central PE or mild and transient in small peripheral PE, according to the European Heart Journal 1
• Pleuritic chest pain is present in 52% of cases, typically caused by pleural irritation due to distal emboli, as reported by the European Heart Journal 1
• Substernal chest pain is present in 12% of cases, may represent right ventricular ischemia, as noted by the European Heart Journal 1
• Syncope is present in 19% of cases, may occur even without hemodynamic instability, according to the European Heart Journal 1
• Hemoptysis is present in 11% of cases, results from alveolar hemorrhage caused by small distal emboli, as reported by the European Heart Journal 1
• Cough is present in 20% of cases, as noted by the European Heart Journal 1
• Tachypnea (respiratory rate >20/min) is present in 70% of cases, as reported by the European Heart Journal 1, 2
• Tachycardia (heart rate >100/min) is present in 26% of cases, according to the European Heart Journal 1, 2
• Signs of deep vein thrombosis are present in 15% of cases, as noted by the European Heart Journal 1, 2
• Fever (>38.5°C) is present in 7% of cases, as reported by the European Heart Journal 1, 2
• Cyanosis is present in 11% of cases, according to the European Heart Journal 1, 2
• Hypotension and shock are hallmarks of central PE with severe hemodynamic consequences, as noted by the European Heart Journal 1, 2

Presentation Based on PE Location

• Central PE often presents with acute and severe dyspnea, as reported by the European Heart Journal 1
• Central PE may also present with substernal chest pain with anginal characteristics, according to the European Heart Journal 1
• Central PE has a higher probability of hemodynamic instability, as noted by the European Heart Journal 1
• Central PE is associated with more frequent syncope, as reported by the European Heart Journal 1
• Peripheral PE often presents with mild and sometimes transient dyspnea, as noted by the European Heart Journal 1
• Peripheral PE may also present with pleuritic chest pain, according to the European Heart Journal 1
• Peripheral PE is associated with hemoptysis, as reported by the European Heart Journal 1
• Peripheral PE may also present with pleural effusion (usually mild), as noted by the European Heart Journal 1

Diagnostic Findings

• Atelectasis or infiltrate is present in 49% of cases on chest X-ray, as reported by the European Heart Journal 1, 2
• Pleural effusion is present in 46% of cases on chest X-ray, according to the European Heart Journal 1, 2
• Pleural-based opacity (infarction) is present in 23% of cases on chest X-ray, as noted by the European Heart Journal 1, 2
• Elevated diaphragm is present in 36% of cases on chest X-ray, as reported by the European Heart Journal 1, 2
• Decreased pulmonary vascularity is present in 36% of cases on chest X-ray, according to the European Heart Journal 1, 2
• Amputation of hilar artery is present in 36% of cases on chest X-ray, as noted by the European Heart Journal 1, 2
• Hypoxemia is present in 75% of cases, although up to 20% of patients may have normal arterial oxygen pressure, as reported by the European Heart Journal 1, 2
• Hypocapnia is often present, according to Praxis Medical Insights 3
• Right ventricular overload is present in 50% of cases on electrocardiogram, as noted by the European Heart Journal 1, 2
• S1Q3T3 pattern (S wave in lead I, Q wave and inverted T wave in lead III) is present on electrocardiogram, as reported by the European Heart Journal 1
• Inversion of T waves in leads V1-V4 is present on electrocardiogram, according to the European Heart Journal 1
• QR pattern in V1 is present on electrocardiogram, as noted by the European Heart Journal 1
• Right bundle branch block (complete or incomplete) is present on electrocardiogram, as reported by the European Heart Journal 1

Special Considerations

• In patients with pre-existing heart failure or pulmonary disease, worsening dyspnea may be the only symptom indicative of PE, as noted by the European Heart Journal 1
• PE can be completely asymptomatic and discovered incidentally during diagnostic studies for other conditions, according to Praxis Medical Insights 3
• Approximately 40% of patients with PE do not have predisposing factors, as reported by Praxis Medical Insights 3

Risk Stratification

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

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, according to Praxis Medical Insights 3
• Do not dismiss transient symptoms, as they can lead to delayed diagnosis or misdiagnosis, as reported by Praxis Medical Insights 4
• Do not overlook PE in patients with pre-existing cardiopulmonary disease where worsening dyspnea may be the only new symptom, as noted by the European Heart Journal 1
• Do not rely solely on individual clinical signs or symptoms, as they lack specificity, according to the European Heart Journal 1, 2

Pulmonary Embolism Diagnosis

Diagnostic Imaging

• When atelectasis is identified on CXR in a patient with suspected pulmonary embolism, further diagnostic testing is still required, as recommended by the American College of Radiology 5, 6
• CT pulmonary angiography (CTPA) remains the first-line diagnostic imaging tool for suspected pulmonary embolism regardless of CXR findings, according to the American College of Radiology 6