A 67-year-old man presents with sudden breathlessness and pleuritic chest pain. CT pulmonary angiography confirms bilateral pulmonary emboli and

Question

A 67-year-old man presents with sudden breathlessness and pleuritic chest pain. CT pulmonary angiography confirms bilateral pulmonary emboli and shows a right-to-left ventricular diameter ratio of 1.2. High-sensitivity troponin T is 53 ng/L (upper reference limit 14 ng/L). His heart rate is 116/min, oxygen saturation is 94% on air and lactate is 1.4 mmol/L. Repeated blood pressures over two hours are 118–126/72–80 mmHg; he is alert with warm peripheries. Renal function is normal. He has no active bleeding, contraindication to anticoagulation or previous anticoagulant treatment. Which initial treatment and disposition plan is most appropriate?

Accepted Answer

Start apixaban and admit for monitored observation with reassessment for deterioration.

Answer

Start apixaban and discharge with ambulatory pulmonary embolism follow-up.

Answer

Start intravenous unfractionated heparin and give systemic alteplase in monitored care.

Answer

Start therapeutic low-molecular-weight heparin and admit for routine ward observation.

Answer

Withhold anticoagulation and arrange an inferior vena cava filter with monitored admission.

Intermediate-high-risk pulmonary embolism — MRCEM SBA MCQ