Clinical features

Signs and symptoms of PE are non specific and have limited sensitivity and specificity in diagnosing the disease (1).

But clinical assessment of patients with suspected pulmonary embolus (PE) is important since the choice of diagnostic tests is determined by the clinical probability of pulmonary embolism (2).

In many cases there are few clinical features.

• new or worsening dyspnoea
  • isolated dyspnoea of rapid onset is usually due to more central PE
  • in some, dyspnoea can be progressive over several weeks and diagnosis of PE is made after ruling out other classic causes of progressive dyspnoea
  • worsening dyspnoea might be the only symptom in patients with pre-existing heart failure or pulmonary disease which is indicative of PE
• chest pain
  • is one of the most frequent presentations (either alone or combined with dyspnoea) of PE
  • can be
    • pleuritic chest pain – caused by pleural irritation
    • retrosternal chest pain – angina like pain may be present in right ventricular ischaemia
• tachypnoea - 20 breaths or more per minute
• tachycardia - greater than 100 beats per minute
• haemoptysis
• syncope – rare, may indicate a severely reduced haemodynamic reserve
• shock and arterial hypotension
• cyanosis
• raised JVP
• pleural rub

Note:

• individual clinical features will have limited diagnostic value when used in isolation to rule in or rule out PE.
  • the probability of having a PE is slightly increased in the presence of syncope, current DVT, leg swelling, sudden dyspnoea, active cancer, surgery, haemoptysis, leg pain or shock
  • the probability is slightly decreased in the absence of dyspnoea or tachypnoea (2)

Reference:

• (1) Torbicki A et al. Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). Eur Heart J. 2008;29(18):2276-315.
• (2) West J, Goodacre S, Sampson F. The value of clinical features in the diagnosis of acute pulmonary embolism: systematic review and meta-analysis. QJM. 2007;100(12):763-9.