Chest
Volume 100, Issue 3, September 1991, Pages 598-603
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Clinical Investigations
Clinical, Laboratory, Roentgenographic, and Electrocardiographic Findings in Patients with Acute Pulmonary Embolism and No Pre-Existing Cardiac or Pulmonary Disease

https://doi.org/10.1378/chest.100.3.598Get rights and content

The history, physical examination, chest radiograph, electrocardiogram and blood gases were evaluated in patients with suspected acute pulmonary embolism (PE) and no history or evidence of pre-existing cardiac or pulmonary disease. The investigation focused upon patients with no previous cardiac or pulmonary disease in order to evaluate the clinical characteristics that were due only to PE. Acute PE was present in 117 patients and PE was excluded in 248 patients. Among the patients with PE, dyspnea or tachypnea (≥20/min) was present in 105 of 117 (90 percent). Dyspnea, hemoptysis, or pleuritic pain was present in 107 of 117 (91 percent). The partial pressure of oxygen in arterial blood on room air was <80 mm Hg in 65 of 88 (74 percent). The alveolar-arterial oxygen gradient was =20 mm Hg in 76 of 88 (86 percent). The chest radiograph was abnormal in 98 of 117 (84 percent). Atelectasis and/or pulmonary parenchymal abnormalities were most common, 79 of 117 (68 percent). Nonspecific ST segment or T wave change was the most common electrocardiographic abnormality, in 44 of 89 (49 percent). Dyspnea, tachypnea, or signs of deep venous thrombosis was present in 107 of 117 (91 percent). Dyspnea or tachypnea or pleuritic pain was present in 113 of 117 (97 percent). Dyspnea or tachypnea or pleuritic pain was present in 113 of 117 (97 percent). Dyspnea or tachypnea or pleuritic pain or atelectasis or a parenchymal abnormality on the chest radiograph was present in 115 of 117 (98 percent). In conclusion, among the patients with pulmonary embolism that were identified, only a small percentage did not have these important manifestations or combinations of manifestations. Clinical evaluation, though nonspecific, is of considerable value in the selection of patients in whom there is a need for further diagnostic studies. (Chest 1991; 100:598-603)

Section snippets

Patient Enrollment

Patients reported in this investigation participated in the national collaborative study of the Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED).4 The eligible population consisted of patients ≥18 years, in whom acute PE was of diagnostic concern. Symptoms suggestive of PE were required within 24 h of entry into the study.4

In the present investigation, we evaluated patients who had no history or evidence of pre-existing cardiac or pulmonary disease. There were 117 patients

RESULTS

Predisposing Factors

Among 117 patients with pulmonary embolism who had no pre-existing cardiac or pulmonary disease, immobilization usually due to surgery was the most prevalent predisposing factor (56 percent of patients) (Table 1). Among the 66 patients in whom immobilization was a predisposing factor, 43 (65 percent) were immobilized ≤ two weeks. Immobilization of two days or less preceded PE in 8 of 117 (7 percent). A history of neoplasia occurred in 23 percent and a history of

Symptoms and Signs

Among 117 patients with PE and no prior cardiac or pulmonary disease, dyspnea was the most common symptom, occurring in 73 percent (Table 3). Pleuritic chain pain (66 percent of patients with PE) occurred much more often than hemoptysis (13 percent of patients with PE). Cough was common (37 percent) among patients with PE, and was sometimes nonproductive, and sometimes productive of clear, bloody or occasionally purulent sputum. Hemoptysis, which occurred in 13 percent of patients with PE, was

Partial Pressure of Oxygen in Arterial Blood

The partial pressure of oxygen in arterial blood (PaO2), was measured while breathing room air in 88 of 117 (75 percent) of patients with PE and in 202 of 248 (81 percent) of patients who did not have PE. Among patients with PE, the PaO2 was 70 ± 16 mm Hg (mean ± SD), and among patients with no PE, it was 72 ± 18 mm Hg (NS). Among patients with PE, the PaO2 was ≥80 mm Hg in 23 of 88 (26 percent), 70-79 mm Hg in 19 of 88 (22 percent), 60-69 mm Hg in 24 of 88 (27 percent), and ≤59 mm Hg in 22 of

Alveolar-Arterial Oxygen Gradient

The alveolar arterial oxygen gradient was 37 ± 17 mm Hg among patients with PE and 35 ± 18 mm Hg among patients in whom PE was excluded (mean ± SD) (NS). The distribution of values of the alveolar-arterial oxygen gradients in patients with and without PE is shown in Figure 2.

Plain Chest Radiograph

According to central readings, the chest radiograph was abnormal in 98 of 117 (84 percent) patients with PE and no prior cardiac or pulmonary disease and it was abnormal in 164 of 247 (66 percent) patients who did not have PE (p <.001). Atelectasis or pulmonary parenchymal abnormalities were the most common radiographic abnormalities, occurring in 79 of 117 (68 percent) with PE and no cardiac or pulmonary disease (Table 5). A pleural effusion occurred in 56 of 117 (48 percent) patients with PE.

Clinical Assessment

Senior staff correctly diagnosed pe in 15 of 17 (88 percent) in whom their clinical assessment indicated a high probability of pe, and fellows correctly diagnosed pe in 26 of 41 (63 percent). This difference in the ability to diagnose pe did not differ significantly between staff and fellows. Fellows were able to correctly exclude pe in 66 of 74 (86 percent) and staff were able to correctly exclude pe in 89 of 103 (89 percent) patients in whom their clinical assessment indicated a low

DISCUSSION

The clinical manifestations of pulmonary embolism, though nonspecific when considered together, can strongly suggest the need for further evaluation.1,8 The present investigation expands upon previous experience and explores the value of several noninvasive tests in patients with pe who have no pre-existing cardiac or pulmonary disease.

A unique feature of this pioped investigation, in comparison to previous studies, was the opportunity to compare the clinical characteristics of patients with pe

ACKNOWLEDGMENT

We thank Drs. Christos Athanasoulis, Matthew Burke, Kyung J. Cho, William J. Fulkerson, Richard H. Greenspan, Mark A. Kelley, Barry A. Lesser, Kenneth V. Leeper, John Popovich Jr., E C. Shetty, B. Taylor Thompson, Carol E. Vreim, and David Williams for their special efforts in relation to this study as well as all of the PIOPED investigators.

REFERENCES (14)

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This study was supported by contracts NO1-HR-34007, NO1-HR 34008, NO1-HR-34009, NO1-HR-34010, NO1-HR-34011, and NO1-HR-34013 from the National Heart, Lung, and Blood Institute, Bethesda, Maryland.

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