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Pulmonary embolism — ABIM Board MCQ

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ModerateCardiovascularPulmonary embolismABIM Board

A 66-year-old woman with metastatic colon cancer presents with acute dyspnea and pleuritic chest pain. Her primary colon tumor was previously resected, and she has no active gastrointestinal bleeding. CT pulmonary angiography shows bilateral segmental pulmonary emboli without right ventricular enlargement. Blood pressure is 126/78 mm Hg, oxygen saturation is 94% on room air, and serum troponin is normal. Platelet count is 165,000/microL, and eGFR is 70 mL/min/1.73 m2. She is not taking medications that strongly induce or inhibit CYP3A4 or P-glycoprotein. Which of the following is the most appropriate initial management?

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Correct answer: E — Therapeutic anticoagulation with apixaban

The correct answer is E. This patient has acute cancer-associated pulmonary embolism and is hemodynamically stable, without right ventricular strain or myocardial injury. She requires immediate therapeutic anticoagulation. Apixaban is appropriate because renal function and platelet count are adequate, the primary gastrointestinal tumor has been resected, and there is no active bleeding or major drug interaction. Initial dosing is 10 mg twice daily for 7 days, followed by 5 mg twice daily. Systemic alteplase is reserved principally for pulmonary embolism causing cardiopulmonary failure or selected patients with impending deterioration. An inferior vena cava filter is generally used when anticoagulation is contraindicated, not as initial monotherapy in an anticoagulation-eligible patient. Prophylactic-dose enoxaparin is inadequate treatment for established pulmonary embolism, and observation risks clot progression and recurrent embolization.

Reference: Creager MA, et al. 2026 AHA/ACC/ACCP/ACEP/CHEST/SCAI/SHM/SIR/SVM/SVN Guideline for the Evaluation and Management of Acute Pulmonary Embolism in Adults, 2026. https://professional.heart.org/en/science-news/2026-guideline-for-the-evaluation-and-management-of-acute-pulmonary-embolism-in-adults/top-things-to-know