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Submassive PE Management — RACP Adult Medicine MCQ

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ModerateRespiratorySubmassive PE ManagementRACP Adult Medicine

A 60-year-old woman with submassive PE (RV dysfunction on echo + elevated troponin, but haemodynamically stable — BP 105/70) is commenced on IV heparin. Her oxygen requirement is increasing (now on 10L O₂). sPESI score is 3. She has no bleeding risk factors. What is the most appropriate management strategy?

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Correct answer: B — Anticoagulation with heparin alone

Submassive PE (intermediate-high risk: RV dysfunction + positive troponin but haemodynamically stable) is managed with anticoagulation (UFH infusion for initial 24-48 hours, then transition to DOAC). Thrombolysis is NOT routinely recommended for submassive PE (PEITHO trial: thrombolysis reduced haemodynamic decompensation but increased major bleeding/ICH without mortality benefit). Close monitoring in HDU/ICU with rescue thrombolysis if haemodynamic deterioration occurs.

Reference: ESC – 2019 – PE; PEITHO Trial; eTG Haematology 2024