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Intermediate-risk pulmonary embolism — ABIM Board MCQ

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HardPulmonary/Critical CareIntermediate-risk pulmonary embolismABIM Board

A 64-year-old has CT-confirmed pulmonary embolism, right-ventricular dilation and elevated troponin. Blood pressure is 124/76 mm Hg, oxygenation is stable and there is no clinical deterioration or contraindication to anticoagulation. What is the best initial treatment?

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Correct answer: A — Begin therapeutic anticoagulation with monitored observation

The best answer is “Begin therapeutic anticoagulation with monitored observation”. This intermediate-risk PE has right-ventricular strain but preserved hemodynamics. Therapeutic anticoagulation and close monitoring are appropriate; routine thrombolysis increases major and intracranial bleeding without sufficient net benefit. Reperfusion becomes a rescue consideration if deterioration occurs. A filter is reserved for selected anticoagulation contraindications, and aspirin is inadequate treatment.

Reference: CHEST Antithrombotic Therapy for VTE Disease Guideline: https://journal.chestnet.org/article/S0012-3692%2824%29900292-7/fulltext