Treatment of Intermediate-Risk Pulmonary Embolism

Abstract

This interactive feature addresses the approach to a clinical issue. A case vignette is followed by specific options, neither of which can be considered either correct or incorrect. In short essays, experts in the field then argue for each of the options as assigned. Readers can participate in forming community opinion by choosing one of the options. C a se Vigne t te A 33-year-old woman presents to her local rural health center with acute-onset dyspnea and chest pain. She has no relevant medical history and takes a combined oral contraceptive for birth control. On examination, she has no fever, and her respiratory rate is 26 breaths per minute, heart rate 122 beats per minute, blood pressure 116/80 mm Hg, and oxygen saturation 92% while she is breathing ambient air. Her right leg is swollen from the upper thigh to below the knee. An electrocardiogram shows sinus tachy-cardia with an incomplete right bundle-branch block. Laboratory tests show a high-sensitivity troponin I level of 92 ng per liter (reference value, <35) and an N-terminal pro-B-type natriuretic peptide (NT-proBNP) level of 2150 pg per milliliter (reference range, 0 to 130). A computed tomo-graphic pulmonary angiogram shows a saddle pulmonary embolism with a clot in the proximal right and left main pulmonary arteries, patchy parenchymal infiltrates, and flattening of the cardiac interventricular septum, with a ratio of right ventricular diameter to left ventricular diameter of 1.0. An echocardiogram shows moderate right ventricular dilatation with a reduced ejection fraction. The patient's vital signs remain unchanged over the course of 30 minutes. You have heard that catheter-directed therapy is being studied in some patients with pulmonary embolism at the nearest referral center, but transferring your patient would involve a 5-hour ground transport. You must decide whether this 33-year-old woman with an acute pulmonary embolism should be treated with standard parenteral heparin alone or whether heparin should be administered in conjunction with a reduced-dose thrombolytic agent. Tre atment Op tions Which one of the following approaches would you take for this patient? Base your choice on the literature, your own experience, published guidelines , and other information. 1. Recommend thrombolysis in addition to hepa-rin therapy. 2. Recommend parenteral heparin therapy only.