Life-threatening recurrent pulmonary embolism following anticoagulation withdrawal: a case report emphasising the management dilemma in resource-constrained settings

Abstract

Introduction: Pulmonary embolism (PE) is a life-threatening condition often presenting diagnostic and therapeutic challenges. Its clinical presentation can mimic cardiac conditions, complicating timely diagnosis. Managing PE, particularly in cases of unprovoked venous thromboembolism (VTE), requires balancing the prevention of recurrence with the risk of bleeding. Case presentation: A 50-year-old woman presented with chest pain and dyspnoea suggestive of acute coronary syndrome. Echocardiography revealed significant right heart strain and a pulmonary artery thrombus. Systemic thrombolysis with alteplase initially improved her condition but led to severe bleeding, necessitating anticoagulation cessation. This interruption resulted in VTE recurrence, with a large thrombus in the right atrium, ultimately proving fatal. Conclusion: This case highlights the diagnostic challenges of PE and the limitations of clinical scoring systems. Imaging played a critical role in confirming the diagnosis. The therapeutic dilemma of balancing anticoagulation to prevent recurrence while minimising bleeding risks underscores the need for tailored management strategies, such as reduced-dose direct oral anticoagulants or catheter-directed thrombolysis. Individualised, dynamic management is essential in complex PE cases. Integrating advanced imaging, risk stratification, and multidisciplinary care can help optimise outcomes while addressing the dual risks of thrombosis and haemorrhage.