• Paul D Stein, Afzal Beemath, Fadi Matta, John G Weg, Roger D Yusen, Charles A Hales, Russell D Hull, Kenneth V Leeper, H Dirk Sostman, Victor F Tapson, John D Buckley, Alexander Gottschalk, Lawrence R Goodman, Thomas W Wakefied, and Pamela K Woodard.
• Department of Research, St. Joseph Mercy Oakland Hospital, Pontiac, Mich 48341-5023, USA. steinp@trinity-health.org
• Am. J. Med. 2007 Oct 1; 120 (10): 871879871-9.

BackgroundSelection of patients for diagnostic tests for acute pulmonary embolism requires recognition of the possibility of pulmonary embolism on the basis of the clinical characteristics. Patients in the Prospective Investigation of Pulmonary Embolism Diagnosis II had a broad spectrum of severity, which permits an evaluation of the subtle characteristics of mild pulmonary embolism and the characteristics of severe pulmonary embolism.MethodsData are from the national collaborative study, Prospective Investigation of Pulmonary Embolism Diagnosis II.ResultsThere may be dyspnea only on exertion. The onset of dyspnea is usually, but not always, rapid. Orthopnea may occur. In patients with pulmonary embolism in the main or lobar pulmonary arteries, dyspnea or tachypnea occurred in 92%, but the largest pulmonary embolism was in the segmental pulmonary arteries in only 65%. In general, signs and symptoms were similar in elderly and younger patients, but dyspnea or tachypnea was less frequent in elderly patients with no previous cardiopulmonary disease. Dyspnea may be absent even in patients with circulatory collapse. Patients with a low-probability objective clinical assessment sometimes had pulmonary embolism, even in proximal vessels.ConclusionSymptoms may be mild, and generally recognized symptoms may be absent, particularly in patients with pulmonary embolism only in the segmental pulmonary branches, but they may be absent even with severe pulmonary embolism. A high or intermediate-probability objective clinical assessment suggests the need for diagnostic studies, but a low-probability objective clinical assessment does not exclude the diagnosis. Maintenance of a high level of suspicion is critical.

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