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Intermediate-risk pulmonary embolism — ABIM Board MCQ

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HardPulmonary/Critical CareIntermediate-risk pulmonary embolismABIM Board

A 57-year-old six days after knee arthroplasty has bilateral segmental pulmonary emboli. Blood pressure is 126/78 mm Hg, troponin is mildly elevated and echocardiography shows right-ventricular dilation. There is no active bleeding. What is the initial management?

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Correct answer: B — Start therapeutic anticoagulation with monitored observation for deterioration

The best answer is “Start therapeutic anticoagulation with monitored observation for deterioration”. This is normotensive PE with evidence of right-ventricular strain. Therapeutic anticoagulation and close monitoring are appropriate; routine thrombolysis exposes the patient to substantial bleeding without established net benefit while stable. Reperfusion becomes appropriate for hemodynamic deterioration or selected rescue situations, and a filter is not a substitute when anticoagulation can be given.

Reference: 2026 AHA/ACC Guideline for Acute Pulmonary Embolism: https://professional.heart.org/en/guidelines-and-statements/guideline-for-the-evaluation-and-management-of-acute-pulmonary-embolism-in-adults