Intermediate-high-risk pulmonary embolism — case discussion

Objectives

1. Classify normotensive pulmonary embolism (PE) with right ventricular (RV) dysfunction and a raised troponin, and plan monitoring and a rescue strategy (ESC 2019).^[1]
2. Choose anticoagulation and plan its duration and follow-up.

Candidate brief

Practice case discussion; this is not a real patient. You are the cardiology registrar asked to see her in the emergency department. In 15 minutes, give your risk assessment, your plan for the first 72 hours, and what you would do if she deteriorated.

Expected actions

• Classify. She has no haemodynamic instability, so she is not high risk; in the intermediate-risk group, with RV dysfunction on CT pulmonary angiography (CTPA) and a raised troponin, she is intermediate-high risk (ESC 2019), and close monitoring is recommended to permit early detection of decompensation.^[1]
• Anticoagulate. Start low-molecular-weight heparin (LMWH), which ESC 2019 recommends over unfractionated heparin (UFH) for most patients if anticoagulation is started parenterally (Class I, level A); ESC 2019 says it appears reasonable to leave intermediate-high-risk patients on LMWH over the first 2–3 days and ensure they remain stable before switching to oral anticoagulation.^[1][2]
• Do not lyse routinely. ESC 2019: routine use of primary systemic thrombolysis is not recommended in intermediate- or low-risk PE (Class III, level B; footnote: the risk-to-benefit ratios of surgical embolectomy or catheter-directed procedures have not yet been established in intermediate- or low-risk PE).^[2]
• Plan ahead. ESC key message: for intermediate-high-risk PE, plan the management strategy with your team prospectively, so a contingency plan is ready if she deteriorates; ESC 2019 also says that set-up of a multidisciplinary team and a programme for the management of high- and (in selected cases) intermediate-risk PE should be considered, depending on the resources and expertise available in each hospital (Class IIa, level C).^[1][2]
• If she deteriorates. ESC 2019: rescue thrombolytic therapy is recommended for haemodynamic deterioration on anticoagulation (Class I, level B); surgical embolectomy or catheter-directed treatment should be considered as an alternative (Class IIa, level C), if appropriate expertise and resources are available on-site.^[2]
• Oral anticoagulation. Once stable, if she is eligible, a non-vitamin K antagonist oral anticoagulant (NOAC) is recommended in preference to a vitamin K antagonist (VKA) (ESC 2019, Class I, level A); NOACs are not recommended in severe renal impairment, pregnancy and lactation, or antiphospholipid antibody syndrome (Class III, level C), none of which applies to her (the row footnote defines severe renal impairment by drug: dabigatran is not recommended with creatinine clearance (CrCl) under 30 mL/min; edoxaban 30 mg once daily at CrCl 15–50 mL/min and not recommended under 15 mL/min; rivaroxaban and apixaban with caution at 15–29 mL/min and not recommended under 15 mL/min).^[2]
• Duration and follow-up. Therapeutic anticoagulation for 3 months or more is recommended (ESC 2019, Class I, level A), and routine clinical evaluation 3–6 months after the PE (for symptoms suggesting recurrence, bleeding, malignancy, or persistent or new-onset exercise limitation, and to decide on extension of anticoagulant treatment) is recommended (Class I, level B). The 2026 AHA/ACC guideline lists oestrogen therapy (hormone replacement or contraceptive) as a minor reversible risk factor, and after a first PE due to a minor reversible risk factor, shared decision-making about stopping anticoagulation at the end of the initial treatment phase (3–6 months) versus continuing into the extended phase is reasonable, to optimise the net clinical benefit of recurrent venous thromboembolism (VTE) versus bleeding (class of recommendation [COR] 2a, level of evidence [LOE] B-NR).^[2][3]

Marking

Pass:

• Classifies her as intermediate-high risk from RV dysfunction plus a raised troponin without haemodynamic instability.^[1]
• Gives anticoagulation with monitoring and reserves thrombolysis for haemodynamic deterioration.^[1][2]

Fail:

• Gives routine primary systemic thrombolysis to a normotensive patient with intermediate-risk PE.^[2]
• Discharges her home on day 1 as low risk.^[1][2]