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High-risk pulmonary embolism with contraindication to thrombolysis — MRCEM SBA MCQ

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HardCardiovascular emergenciesHigh-risk pulmonary embolism with contraindication to thrombolysisMRCEM SBA

A 59-year-old man presents to a district general hospital with sudden breathlessness and syncope. CT pulmonary angiography confirms extensive bilateral pulmonary emboli. Despite cautious intravenous fluid and a noradrenaline infusion, his blood pressure is 78/46 mmHg; echocardiography shows a dilated, poorly contracting right ventricle. Five weeks ago he underwent a major laparotomy for bowel obstruction. His recovery was uncomplicated, his wound is healed, and he has no active bleeding. He has not yet received anticoagulation. The regional centre can accept him immediately for mechanical pulmonary thrombectomy; surgical embolectomy is unavailable. Monitoring and intravenous access are established. Which treatment and disposition plan is most appropriate?

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

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Correct answer: C — Begin continuous intravenous unfractionated heparin and arrange regional mechanical pulmonary thrombectomy.

Persistent shock with confirmed PE and right ventricular failure identifies a high-risk PE requiring urgent consideration of reperfusion, not anticoagulation alone. NICE recommends a continuous intravenous unfractionated heparin infusion for PE with haemodynamic instability. The healed wound and absence of active bleeding do not remove the separate contraindication to alteplase: its UK product information lists major surgery within the preceding three months. Because thrombolysis is unsuitable, surgical embolectomy is unavailable, and the regional centre can receive him immediately, urgent specialist-led mechanical pulmonary thrombectomy is the best plan. NICE permits this procedure for high-risk PE when alternatives are unsuitable, subject to its special governance arrangements. A would be attractive for shock from PE without a thrombolysis contraindication, but the recent laparotomy rules out alteplase here. B offers a lower-dose, catheter-directed approach, yet still exposes him to a thrombolytic; it could be considered if thrombolysis were suitable. D provides necessary support but leaves the obstructing emboli untreated despite an available reperfusion option; it would be more defensible if no reperfusion treatment were feasible. E may be considered when anticoagulation is contraindicated, but it does not relieve this established, shock-producing PE, and anticoagulation is being given.

Reference: NICE NG158: Venous thromboembolic diseases, recommendations 1.3.12 and 1.6.2 (2020) — https://www.nice.org.uk/guidance/ng158/chapter/Recommendations NICE HTG705: Percutaneous thrombectomy for intermediate-risk or high-risk pulmonary embolism (29 November 2023) — https://www.nice.org.uk/guidance/htg705/resources/percutaneous-thrombectomy-for-intermediaterisk-or-highrisk-pulmonary-embolism-pdf-1809600523133893 Actilyse Summary of Product Characteristics, section 4.3 (8 May 2026) — https://www.medicines.org.uk/emc/medicine/308