Pulmonary embolism: clinical findings were not very helpful.

Clinical bottom line (level 4)

  1. No individual clinical sign, symptom or non-invasive test was good enough to rule in or rule out pulmonary embolism. Clinicians needed a high level of suspicion to consider it as a diagnosis and further tests were needed.
  2. Patients ranked by clinicians as high risk for pulmonary embolism were at increased risk (LR+3.7) , and patients ranked as low risk were at less risk (LR-0.26) .
  3. 98% of patients with a pulmonary embolism had at least one of the following:
    • dyspnoea
    • tachypnoea
    • pleuritic pain
    • atelectasis or pulmonary parenchymal abnormality on chest x-ray
  4. Patients with a normal chest X-ray were less likely to have a pulmonary embolism (LR-0.48) , but further tests were needed to rule it out.
Stein et al: Chest 1991; 100 (3): 598-603
Expires October 2003

The study

Setting: tertiary medical centres, USA

365 patients (aged range 31 to 71 years; mean ~50, 60%% female) suspected pulmonary embolism and no pre-existing heart or lung disease, referred for ventilation-perfusion scan (117 patients with PE and 248 in whom PE was excluded). 'No pre-existing heart or lung disease' if no history or evidence of:
  • valvular heart disease
  • coronary artery disease
  • myocardial infarction
  • 'other heart disease'
  • congestive cardiac failure
  • asthma
  • COPD
  • interstitial lung disease
  • 'other lung disease'
  • no recognised acute pneumonia or acute respiratory distress syndrome


Excluded if
  • aged <18



    • Non-independent blinded reference standard, applied in all patients from a consecutive inappropriate spectrum.
    Reference standard:
    • pulmonary angiogram or follow-up
    Diagnostic test:
    • history and physical examination
    • arterial blood gas
    • chest x-ray (AP and lateral) within 24 hours of angiogram
    • 12 lead ECG 24 hours before angiogram

    • Clinicians ranked patients as high, uncertain or low probability for PE based on history, physical and all non-invasive investigations.

    The evidence

    pre-test probability of pulmonary embolism: 32%, (95% CI: 27% to 37%)

    diagnostic test pulmonary embolism no pulmonary embolism LR+
    (95% CI)    		 post-test probability LR-
    (95% CI)    		 post-test probability
    risk factors: immobilisation 66 81 1.7
    (1.4 to 2.2)     		45% 0.65
    (0.52 to 0.81)     		23%
    risk factor: surgery 63 78 1.7
    (1.3 to 2.2)     		45% 0.67
    (0.54 to 0.83)     		24%
    total 117 248


    diagnostic test pulmonary embolism no pulmonary embolism LR+
    (95% CI)    		 post-test probability LR-
    (95% CI)    		 post-test probability
    symptoms: pleuritic pain or haemoptysis (without circulatory collapse) 76 147 1.1
    (0.93 to 1.3)     		34% 0.86
    (0.64 to 1.2)     		29%
    dyspnoea (without haemoptysis, pleuritic pain, loss of consciousness, or shock) 26 52 1.1
    (0.70 to 1.6)     		33% 0.98
    (0.88 to 1.1)     		32%
    circulatory collapse (shock or loss of consciousness) 9 22 0.87
    (0.41 to 1.8)     		29% 1.0
    (0.95 to 1.1)     		32%
    dyspnoea 85 178 1.0
    (0.88 to 1.2)     		32% 0.97
    (0.68 to 1.4)     		31%
    pleuritic pain 77 146 1.1
    (0.95 to 1.3)     		35% 0.83
    (0.62 to 1.1)     		28%
    cough 43 89 1.0
    (0.77 to 1.4)     		33% 0.99
    (0.84 to 1.2)     		32%
    leg swelling 33 55 1.3
    (0.88 to 1.8)     		38% 0.92
    (0.81 to 1.1)     		30%
    leg pain 30 60 1.1
    (0.73 to 1.6)     		33% 0.98
    (0.86 to 1.1)     		32%
    haemoptysis 15 20 1.6
    (0.84 to 3.0)     		43% 0.95
    (0.88 to 1.0)     		31%
    palpitations 12 44 0.58
    (0.32 to 1.1)     		21% 1.1
    (1.0 to 1.2)     		34%
    wheezing 10 28 0.76
    (0.38 to 1.5)     		26% 1.0
    (0.96 to 1.1)     		33%
    angina-like pain 5 15 0.71
    (0.26 to 1.9)     		25% 1.0
    (0.97 to 1.1)     		32%
    total 117 248


    diagnostic test pulmonary embolism no pulmonary embolism LR+
    (95% CI)    		 post-test probability LR-
    (95% CI)    		 post-test probability
    signs: tachypnoea (> 20/min) 82 169 1.0
    (0.89 to 1.2)     		33% 0.94
    (0.67 to 1.3)     		31%
    crackles 60 98 1.3
    (1.0 to 1.6)     		38% 0.81
    (0.65 to 1.0)     		28%
    tachycardia (> 100/ min) 35 59 1.3
    (0.88 to 1.8)     		37% 0.92
    (0.80 to 1.1)     		30%
    4th heart sound 28 34 1.8
    (1.1 to 2.7)     		45% 0.88
    (0.79 to 0.99)     		29%
    increased pulmonary component of 2nd heart sound 27 33 1.7
    (1.1 to 2.7)     		45% 0.89
    (0.79 to 0.99)     		30%
    DVT 13 27 1.0
    (0.55 to 1.9)     		33% 1.0
    (0.92 to 1.1)     		32%
    sweating 13 20 1.4
    (0.71 to 2.7)     		39% 0.97
    (0.90 to 1.0)     		31%
    temperature >38.5°C 8 29 0.58
    (0.28 to 1.2)     		22% 1.1
    (0.99 to 1.1)     		33%
    wheeze 6 21 0.61
    (0.25 to 1.5)     		22% 1.0
    (0.98 to 1.1)     		33%
    Homan's sign 5 6 1.8
    (0.55 to 5.7)     		45% 0.98
    (0.94 to 1.0)     		32%
    right ventricular lift 5 6 1.8
    (0.55 to 5.7)     		45% 0.98
    (0.94 to 1.0)     		32%
    pleural friction rub 3 6 1.1
    (0.27 to 4.2)     		33% 1.0
    (0.96 to 1.0)     		32%
    third heart sound 3 11 0.58
    (0.16 to 2.0)     		21% 1.0
    (0.98 to 1.1)     		32%
    cyanosis 1 5 0.42
    (0.05 to 3.6)     		17% 1.0
    (0.99 to 1.0)     		32%
    total 117 248


    diagnostic test pulmonary embolism no pulmonary embolism LR+
    (95% CI)    		 post-test probability LR-
    (95% CI)    		 post-test probability
    chest x-ray: abnormal 98 164 1.3
    (1.1 to 1.4)     		37% 0.48
    (0.31 to 0.75)     		18%
    atelectasis or pulmonary parenchymal abnormality 79 119 1.4
    (1.2 to 1.7)     		40% 0.62
    (0.47 to 0.83)     		23%
    pleural effusion 56 77 1.5
    (1.2 to 2.0)     		42% 0.76
    (0.62 to 0.92)     		26%
    pleural-based opacity 41 53 1.6
    (1.2 to 2.3)     		44% 0.83
    (0.71 to 0.96)     		28%
    elevated diaphragm 28 46 1.3
    (0.85 to 2.0)     		38% 0.93
    (0.83 to 1.1)     		31%
    decreased pulmonary vasculature 25 30 1.8
    (1.1 to 2.9)     		45% 0.89
    (0.81 to 0.99)     		30%
    prominent central pulmonary artery 17 28 1.3
    (0.73 to 2.3)     		38% 0.96
    (0.88 to 1.1)     		31%
    cardiomegaly 14 27 1.1
    (0.60 to 2.0)     		34% 0.99
    (0.91 to 1.1)     		32%
    Westermark's sign (prominent pulmonary artery and decreased pulmonary vasculature) 8 6 2.8
    (1.0 to 8.0)     		57% 0.95
    (0.91 to 1.0)     		31%
    pulmonary oedema 5 31 0.34
    (0.14 to 0.86)     		14% 1.1
    (1.1 to 1.2)     		34%
    total 117 248


    diagnostic test pulmonary embolism no pulmonary embolism LR
    (95% CI)    		 post-test probability
    clinical suspicion high 26 15 3.7
    (2.0 to 6.7)     		63%
    clinical suspicion uncertain 83 167 1.1
    (0.91 to 1.2)     		33%
    clinical suspicion low 8 66 0.26
    (0.13 to 0.52)     		11%
    total 117 248

    • combinations:
      • dyspnoea or tachypnoea: PE 105/117; 90%
      • dyspnoea or tachypnoea or DVT signs: PE 107/117; 91%
      • dyspnoea or tachypnoea or pleuritic pain: PE 113/117; 97%
      • dyspnoea or tachypnoea or pleuritic pain, or atelectasis or pulmonary parenchymal abnormality on chest x-ray: PE 115/117; 98%
    • The above combinations were equally prevalent in patients without PE.
    • No combination of signs or symptoms was found to be helpful in diagnosing PE.

    Citation

    1. Stein PD, Terrin ML, Hales CA, et al: Clinical, laboratory, roentgenographic, and electrocardiographic findings in patients with acute pulmonary embolism and no pre-existing cardiac or pulmonary disease. Chest 1991; 100 (3): 598-603
    Contributor: Chris Ball and Clare Wotton, October 2000
    Reviewer:

    Clinical Question.
    Patient suspected pulmonary embolism
    Intervention or Exposure signs and symptoms
    Outcome diagnosis