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Haemodynamically stable pulmonary embolism with right ventricular dysfunction and myocardial injury — MRCEM SB

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HardRespiratory emergenciesHaemodynamically stable pulmonary embolism with right ventricular dysfunction and myocardial injuryMRCEM SBA

A 57-year-old man presents with sudden pleuritic chest pain and breathlessness. CTPA confirms bilateral pulmonary emboli and shows a right-to-left ventricular diameter ratio of 1.2. His troponin is above the laboratory reference range. After analgesia, his pulse remains 116/min and his blood pressure is 124/76 mmHg on repeated measurements. His SpO₂ is 94% on oxygen at 2 L/min via nasal cannulae. He is alert and can take oral medication. Renal and hepatic function are normal; he has no active cancer, known antiphospholipid syndrome or contraindication to anticoagulation. What is the most appropriate initial treatment and disposition?

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

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Correct answer: B — Start oral apixaban and admit for monitored observation.

This is confirmed PE with right ventricular dilatation and biochemical evidence of myocardial injury, but **not haemodynamic instability**: repeated blood pressures remain normal. The ventricular and troponin findings make early deterioration a concern, so he needs inpatient observation rather than selection for a low-risk outpatient pathway. UK specialty guidance specifically advises inpatient observation when right ventricular dilatation is accompanied by an elevated cardiac biomarker. ([bmjopenrespres.bmj.com](https://bmjopenrespres.bmj.com/content/bmjresp/5/1/e000281.full.pdf?utm_source=openai)) Anticoagulation should begin now. With preserved renal function and none of the stated exceptions, apixaban is a NICE-recommended initial option for confirmed PE. NICE advises against systemic thrombolysis in haemodynamically stable PE, even when right ventricular dysfunction is present; it reserves consideration of thrombolysis for haemodynamic instability. Thus **B** combines the appropriate treatment with the appropriate disposition. ([nice.org.uk](https://www.nice.org.uk/guidance/ng158/chapter/Recommendations)) **A** gets the anticoagulant right but overlooks the findings that warrant observation; it would suit a patient assessed as low risk for outpatient care. **C** overreacts to ventricular strain and troponin elevation: these do not substitute for haemodynamic instability as a thrombolysis indication. **D** describes an alternative NICE regimen when apixaban or rivaroxaban is unsuitable, which is not established here. **E** uses a heparin strategy particularly relevant to unstable PE or other circumstances requiring it, rather than the recommended oral option for this stable patient. ([nice.org.uk](https://www.nice.org.uk/guidance/NG158/chapter/recommendations))

Reference: NICE NG158: Venous thromboembolic diseases — recommendations 1.2.1, 1.3.8, 1.3.12 and 1.6.2–1.6.3 (2 August 2023) — https://www.nice.org.uk/guidance/ng158/chapter/Recommendations British Thoracic Society Guideline for the initial outpatient management of pulmonary embolism (2018) — https://bmjopenrespres.bmj.com/content/bmjresp/5/1/e000281.full.pdf