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A Symptoms and Signs
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The clinical diagnosis of PE is notoriously difficult for two reasons First, the clinical findings depend on both the size of the embolus and the patient s preexisting cardiopulmonary status Second, common symptoms and signs of pulmonary emboli are not specific to this disorder (Table 9 16) Indeed, no single symptom or sign or combination of clinical findings is specific to PE Some findings are fairly sensitive: dyspnea and pain on inspiration occur in 75 85% and 65 75% of patients, respectively Tachypnea is the only sign reliably found in more than half of patients A common clinical strategy is to use combinations of
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Table 9 16 Frequency of specific symptoms and signs in patients at risk for pulmonary thromboembolism
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UPET1 PE+ (n = 327) Symptoms Dyspnea Respirophasic chest pain Cough Leg pain Hemoptysis Palpitations Wheezing Anginal pain Signs Respiratory rate 16 UPET, 20 PIOPED I Crackles (rales) Heart rate 100/min Fourth heart sound (S4) Accentuated pulmonary component of second heart sound (S2P) T 375 C UPET, 385 C PIOPED Homans sign Pleural friction rub Third heart sound (S3) Cyanosis
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PIOPED2 PE+ (n = 117)
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PIOPED2 PE (n = 248)
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84% 74% 53% nr 30% nr nr 14% 92% 58% 44% nr 53% 43% nr nr nr 19%
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73% 66% 37% 26% 13% 10% 9% 4% 70% 51% 30% 24% 23% 7% 4% 3% 3% 1%
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72% 59% 36% 24% 8% 18% 11% 6% 68% 40%3 24% 13%3 13%3 12% 2% 2% 4% 2%
Data from the Urokinase-Streptokinase Pulmonary Embolism Trial, as reported in Bell WR, Simon TL, DeMets DL The clinical features of submassive and massive pulmonary emboli Am J Med 1977;62:355 2 Data from patients enrolled in the PIOPED I study, as reported in Stein PD et al Clinical, laboratory, roentgenographic, and electrocardiographic findings in patients with acute pulmonary embolism and no preexisting cardiac or pulmonary disease Chest 1991;100:598 3 P < 05 comparing patients in the PIOPED I study PE+, confirmed diagnosis of pulmonary embolism; PE , diagnosis of pulmonary embolism ruled out; nr, not reported
clinical findings to identify patients at low risk for PE For example, 97% of patients in the original Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED I) study with angiographically proved pulmonary emboli had one or more of three findings: dyspnea, chest pain with breathing, or tachypnea Wells and colleagues have published and validated a simple clinical decision rule that quantifies and dichotomizes this clinical risk assessment, allowing diversion of patients deemed unlikely to have PE to a simpler diagnostic algorithm (see Integrated Approach to Diagnosis of Pulmonary Embolism)
B Laboratory Findings
The ECG is abnormal in 70% of patients with PE However, the most common abnormalities are sinus tachycardia and nonspecific ST and T wave changes, each seen in approximately 40% of patients Five percent or less of patients in the PIOPED I study had P pulmonale, right ventricular hypertrophy, right axis deviation, and right bundle branch block Arterial blood gases usually reveal acute respiratory alkalosis due to hyperventilation The arterial PO2 and the
alveolar-arterial oxygen difference (A a DO2) are usually abnormal in patients with PE compared with healthy, agematched controls However, arterial blood gases are not diagnostic: among patients who were evaluated in the PIOPED I study, neither the PO2 nor the A a DO2 differentiated between those with and those without pulmonary emboli Profound hypoxia with a normal chest radiograph in the absence of preexisting lung disease is highly suspicious for PE Plasma levels of D-dimer, a degradation product of cross-linked fibrin, are elevated in the presence of thrombus Using a D-dimer threshold between 300 and 500 ng/mL, a rapid quantitative enzyme-linked immunosorbent assay (ELISA) has shown a sensitivity for venous thromboembolism of 95 97% and a specificity of 45% Therefore, a Ddimer < 500 ng/mL using most rapid ELISA provides strong evidence against venous thromboembolism, with a likelihood ratio of 011 013 Appropriate diagnostic thresholds have not been established for patients in whom D-dimer is elevated Serum troponin I, troponin T, and plasma betanatriuretic peptide (BNP) levels are typically higher in
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