A 62-year-old woman with a history of recent hip fracture (immobilized for 2 weeks) presents with acute onset dyspnea and syncope. On examination: BP 88/54 mmHg, HR 128/min, RR 32/min, JVD present, right ventricular heave palpable. Troponin is elevated at 0.18 ng/mL (normal <0.04). Bedside echocardiography shows RV dilatation with RV/LV ratio 1.8 and elevated TR velocity. What is the most appropriate immediate management?

Explanation

## Clinical Recognition: Massive PE This patient has **haemodynamic instability** (BP 88/54 mmHg, syncope) with **RV dysfunction** (RV/LV ratio 1.8, elevated TR velocity on echo) and **myocardial injury** (troponin 0.18 ng/mL). This constellation defines **massive (high-risk) PE**—a medical emergency with mortality >30% if untreated. ## Why Immediate Thrombolysis Is the Correct Answer **Key Point:** Per ESC 2019 and AHA 2011 guidelines, haemodynamically unstable PE (SBP <90 mmHg or cardiogenic shock) is an **absolute indication for systemic thrombolysis** unless a contraindication exists. This patient has no stated contraindication. The correct sequence in massive PE with confirmed/highly suspected diagnosis (bedside echo already showing RV dilatation + elevated TR velocity) is: 1. **Administer alteplase 100 mg IV over 2 hours** — standard regimen: 10 mg IV bolus, then 90 mg over 2 hours 2. **Obtain CTPA** — for confirmation, but treatment must NOT be delayed for imaging when clinical + echo evidence is compelling and the patient is in shock **Option A is correct** because it prioritizes immediate reperfusion therapy (alteplase) in a patient who is already in obstructive shock with echocardiographic confirmation of massive PE. Waiting for CTPA before thrombolysis in this context is inappropriate and potentially fatal. ## Why Other Options Are Incorrect | Option | Problem | |--------|---------| | **B (UFH + CTPA)** | Anticoagulation alone is insufficient for massive PE with haemodynamic collapse; thrombolysis is indicated, not merely anticoagulation | | **C (Oxygen + noradrenaline + "consider" thrombolysis)** | Vasopressors are supportive but do not treat the obstruction; "consider thrombolysis" is too soft — thrombolysis is **indicated**, not optional, in haemodynamically unstable PE. This sequence delays definitive therapy | | **D (IVC filter)** | IVC filters prevent new emboli from lower-limb DVT but do NOT treat existing PE; deferring anticoagulation is dangerous and not guideline-supported | ## Thrombolysis in Massive PE **High-Yield:** Alteplase (t-PA) is the thrombolytic of choice for massive PE: - **Regimen:** 10 mg IV bolus + 90 mg over 2 hours (total 100 mg) - Haemodynamic improvement often seen within 30–60 minutes - UFH is held during alteplase infusion and restarted (without bolus) when aPTT <80 seconds after infusion ends **Clinical Pearl (Harrison's Principles, 21st ed.; ESC PE Guidelines 2019):** In massive PE, bedside echocardiography showing RV dilatation + haemodynamic instability is sufficient to initiate thrombolysis without waiting for CTPA. CTPA is obtained after stabilization for confirmation and to guide further management. ## Contraindications to Thrombolysis (None Present Here) - Active internal bleeding (not stated) - Recent intracranial surgery/trauma/stroke (not stated) - Intracranial neoplasm (not stated) This patient has a hip fracture (immobilization as risk factor) but no absolute contraindication to thrombolysis is mentioned, making alteplase the correct immediate intervention.