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Intermediate-high-risk acute pulmonary embolism — SCE Respiratory MCQ

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HardThrombolysisIntermediate-high-risk acute pulmonary embolismSCE Respiratory

A 58-year-old man presents 36 hours after the onset of dyspnoea and pleuritic chest pain. CT pulmonary angiography shows bilateral proximal pulmonary emboli and a right ventricular:left ventricular diameter ratio of 1.4. High-sensitivity troponin is elevated. His simplified Pulmonary Embolism Severity Index is 1. His blood pressure has remained between 104/68 and 110/72 mmHg for 3 hours, without a fall of 40 mmHg from baseline. His heart rate is 118 beats/min and respiratory rate 28 breaths/min. He is alert, peripherally warm and passing urine; lactate is 1.8 mmol/L. Therapeutic anticoagulation has been started. He has no major bleeding risk or contraindication to thrombolysis. The hospital can provide ultrasound-facilitated catheter-directed thrombolysis. Which is the most appropriate immediate management strategy under current UK guidance?

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

Reveal the answer and explanation

Correct answer: A — Continue therapeutic anticoagulation in a monitored setting, reserving reperfusion for haemodynamic deterioration

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

This is intermediate-high-risk PE: he is normotensive but has both RV dysfunction and myocardial injury. His tachycardia, tachypnoea and low-normal systolic pressure indicate increased risk of deterioration, but he has no persistent hypotension, shock or tissue hypoperfusion. Current NICE guidance therefore supports therapeutic anticoagulation and close inpatient monitoring, not systemic thrombolysis. Reperfusion should be deployed as rescue treatment if haemodynamic instability develops. A is attractive because systemic thrombolysis reduces haemodynamic decompensation in intermediate-risk PE, but PEITHO demonstrated increased major bleeding and haemorrhagic stroke without a mortality benefit; NICE advises against systemic thrombolysis while haemodynamic stability persists. B reflects the positive 2026 HI-PEITHO trial, but ultrasound-facilitated catheter-directed fibrinolysis has not yet become routine UK care: current NICE procedural guidance requires special governance, consent, audit or research arrangements. D is not an established UK standard; reduced-dose systemic thrombolysis remains under evaluation rather than recommended routine treatment. E is inappropriate without haemodynamic collapse. Surgical embolectomy is principally an alternative reperfusion strategy for high-risk PE when thrombolysis is contraindicated or has failed.

Reference: Venous thromboembolic diseases: diagnosis, management and thrombophilia testing — Recommendations (Last updated 2 August 2023) — https://www.nice.org.uk/guidance/ng158/chapter/Recommendations Ultrasound-enhanced, catheter-directed thrombolysis for pulmonary embolism (Published 26 June 2015; current NICE guidance checked 18 August 2026) — https://www.nice.org.uk/guidance/htg376 Ultrasound-Facilitated, Catheter-Directed Fibrinolysis for Acute Pulmonary Embolism (2026) — https://pubmed.ncbi.nlm.nih.gov/41910345/