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Acute pulmonary embolism — SCE Respiratory MCQ

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HardDispositionAcute pulmonary embolismSCE Respiratory

A 67-year-old man presents with acute pleuritic chest pain and dyspnoea. He has no cancer, chronic cardiopulmonary disease or previous venous thromboembolism. His heart rate is 106 beats/min, blood pressure 104/68 mmHg and oxygen saturation 92% on air. He is alert, his pain is controlled with paracetamol and he can mobilise independently. CT pulmonary angiography confirms bilateral segmental pulmonary emboli and shows a right ventricular-to-left ventricular diameter ratio of 1.15. High-sensitivity troponin I is 68 ng/L (upper reference limit 34 ng/L). ECG shows sinus tachycardia without ischaemic changes. Haemoglobin, platelet count and liver function are normal; eGFR is 68 mL/min/1.73 m². There is no active bleeding or recent surgery. He lives with his partner, has telephone access and can attend follow-up. A formal outpatient pulmonary embolism pathway is available. Which initial management and disposition plan is most appropriate?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: B — Inpatient admission for observation and therapeutic anticoagulation without routine reperfusion

Explanation lettering: B = shown as A · C = shown as B · A = shown as C

His sPESI is 0: he is younger than 80 years, has no cancer or chronic cardiopulmonary disease, and remains above the adverse thresholds of heart rate 110 beats/min, systolic pressure 100 mmHg and oxygen saturation 90%. He also has no clinical or social exclusion criterion, so he initially appears eligible for outpatient treatment. However, CT has demonstrated right ventricular dilatation. BTS guidance advises cardiac biomarker measurement when RV dilatation is identified in an otherwise outpatient-eligible patient; an elevated troponin or natriuretic peptide should prompt inpatient admission for observation. Therapeutic anticoagulation should therefore be commenced in hospital. A is inappropriate because sPESI eligibility does not override the combination of RV dilatation and elevated troponin. B incorrectly applies an acute-coronary-syndrome serial-troponin strategy: a non-rising value does not negate the BTS disposition recommendation. D is excessive because NICE advises against systemic thrombolysis in haemodynamically stable PE, including when RV dysfunction is present; reperfusion is reserved for haemodynamic deterioration or instability. E is likewise unjustified: catheter-directed intervention is not routine treatment for a stable patient responding to anticoagulation and is generally considered when reperfusion is required but systemic thrombolysis is unsuitable or unsuccessful.

Reference: British Thoracic Society Guideline for the initial outpatient management of pulmonary embolism (June 2018) — https://www.brit-thoracic.org.uk/document-library/guidelines/ambulatory-pe/bts-guideline-for-the-initial-outpatient-management-of-pulmonary-embolism/ Venous thromboembolic diseases: diagnosis, management and thrombophilia testing (NICE guideline NG158) (2 August 2023) — https://www.nice.org.uk/guidance/ng158/chapter/Recommendations