A 38-year-old woman presents with a 3-day history of progressive dyspnea, chest pain, and hemoptysis. She returned from a 12-hour flight 5 days ago. On examination, she is tachycardic (HR 118/min), tachypneic (RR 28/min), and oxygen saturation is 88% on room air. D-dimer is elevated at 2.8 µg/mL (normal <0.5). CT pulmonary angiography (CTPA) shows a segmental pulmonary artery occlusion in the right lower lobe. Doppler ultrasound of the lower limbs shows no evidence of deep vein thrombosis. Which of the following is the most appropriate immediate management?

Explanation

## Diagnosis and Risk Stratification **Key Point:** This patient has acute pulmonary embolism (PE) confirmed by CTPA with hemodynamic stability (no shock, no RV dysfunction on clinical grounds) and a clear risk factor (recent immobility from air travel). ### Clinical Assessment - **Presentation:** Dyspnea, chest pain, hemoptysis, tachycardia, tachypnea, hypoxia - **Risk factors:** Recent long-haul flight (immobility) - **Imaging:** CTPA-confirmed segmental PE - **Hemodynamics:** Normotensive, no mention of cardiogenic shock or syncope ### Management Algorithm for Acute PE ```mermaid flowchart TD A[Acute PE confirmed by CTPA]:::outcome --> B{Hemodynamically stable?}:::decision B -->|Yes| C{High-risk features?}:::decision B -->|No| D[Thrombolysis + ICU]:::action C -->|No high-risk| E[Anticoagulation: UFH/LMWH/DOACs]:::action C -->|RV dysfunction, troponin elevation| F[Consider thrombolysis]:::action E --> G[Transition to warfarin or DOAC]:::action F --> G G --> H[Long-term anticoagulation 3+ months]:::action ``` **High-Yield:** Anticoagulation is the standard of care for hemodynamically stable PE. Thrombolysis is reserved for hemodynamic instability (shock, syncope) or massive PE with RV dysfunction. ### Why Anticoagulation? 1. **Prevents clot propagation** and recurrent thromboembolism 2. **Allows endogenous fibrinolysis** to dissolve the clot 3. **First-line agents:** Unfractionated heparin (UFH), low-molecular-weight heparin (LMWH), or fondaparinux 4. **Transition:** After 5–10 days of parenteral anticoagulation, switch to warfarin (INR 2–3) or direct oral anticoagulant (DOAC) for long-term management **Clinical Pearl:** In this case, the patient is hemodynamically stable (normotensive, no syncope), so thrombolysis is NOT indicated. Observation without anticoagulation risks clot propagation and recurrent PE. **High-Yield:** IVC filters are reserved for: - Contraindications to anticoagulation (active bleeding, HIT) - Recurrent PE despite adequate anticoagulation - NOT for primary prevention in stable PE