Case studies · Medicine · 23 October 2026

Pulmonary embolism case study

The case

Patient: A 58‑year‑old male, Mr A, presents to the emergency department with sudden onset shortness of breath.

Presenting complaint:

• Dyspnoea at rest for 3 hours, progressively worsening.
• Pleuritic chest pain on the left side, sharp, aggravated by deep inspiration.
• Light‑headedness and a single episode of near‑syncope while walking to the bathroom.

History of present illness:

• Symptoms began abruptly while the patient was watching television.
• No prior similar episodes.
• No recent trauma, surgery, or prolonged immobilisation.
• Denies cough, fever, wheeze, or haemoptysis.

Past medical history:

• Hypertension for 10 years, on amlodipine 5 mg daily.
• Type 2 diabetes mellitus, on metformin 500 mg twice daily.
• Obesity (BMI = 32 kg/m²).

Social history:

• Former smoker, 20 pack‑years, quit 5 years ago.
• Works as a sales manager; recent business trip involved a 12‑hour flight 4 days ago.
• No regular alcohol intake.

Family history:

• Father died of myocardial infarction at 62 years.
• Mother has osteoarthritis.

Examination:

Initial investigations:

The patient is diagnosed with acute pulmonary embolism (PE) with right‑ventricular (RV) strain.

Questions

1. What is the most likely diagnosis and which clinical and investigation findings support it?
2. Using the ESC 2022 risk stratification algorithm, into which risk category does this patient fall and why?
3. What are the immediate management steps for this patient, including anticoagulation and reperfusion options?
4. Which further investigations are indicated to identify underlying aetiology and to assess prognosis?
5. Discuss the potential short‑term and long‑term complications of pulmonary embolism and their preventive strategies.

Answers

1. Diagnosis and supporting findings

Diagnosis: Acute pulmonary embolism (PE).

Key supporting elements:

Together, the acute onset, risk profile, objective evidence of RV strain (troponin, ECG), and definitive CTPA findings fulfill the diagnostic criteria for PE.

2. ESC 2022 risk stratification

The European Society of Cardiology (ESC) 2022 guideline classifies acute PE into high‑risk (massive), intermediate‑high, intermediate‑low, and low‑risk based on haemodynamic status, RV dysfunction, and myocardial injury.

Step‑wise assessment for this patient:

1. Haemodynamic stability:

   • BP 138/84 mm Hg (systolic ≥ 90 mm Hg) → stable → not high‑risk.

2. RV dysfunction:

   • Echocardiography (not yet performed) would likely show RV dilatation; however, surrogate markers are present:
     • ECG S1Q3T3, right‑axis deviation.
     • Troponin‑I mildly elevated (0.04 ng/mL).
   • CTPA may show RV/LV diameter ratio > 0.9 (not reported but probable).

3. Myocardial injury:

   • Troponin‑I above the upper limit of normal → positive.

Risk category:

• Intermediate‑high risk (stable haemodynamics + both RV dysfunction and myocardial injury).

Rationale: The patient meets the ESC criteria for intermediate‑high risk because he is haemodynamically stable but has evidence of RV strain (ECG, probable imaging) and a positive cardiac biomarker. This categorisation guides the need for close monitoring and consideration of early reperfusion if deterioration occurs.

3. Immediate management

A. Initial stabilisation

B. Anticoagulation (first‑line)

• Choice: Low‑molecular‑weight heparin (LMWH) – enoxaparin 1 mg/kg subcutaneously every 12 h (adjust for renal function; CrCl > 30 mL/min).
• Alternative (if renal impairment or contraindication): Unfractionated heparin (UFH) bolus 80 U/kg IV followed by infusion targeting aPTT 1.5–2.5 × control.
• Rationale: Immediate anticoagulation reduces clot propagation and mortality; LMWH preferred per ACCP 2023 guideline (Grade 1A).

C. Reperfusion considerations

• Indication: High‑risk (massive) PE or clinical deterioration (hypotension, shock, persistent hypoxaemia).

• Current status: Patient is intermediate‑high risk, haemodynamically stable. Routine systemic thrombolysis is not indicated.

• Potential options if deterioration occurs:

  1. Systemic thrombolysis – alteplase 100 mg IV over 2 h (or 0.6 mg/kg, max 50 mg).
  2. Catheter‑directed thrombolysis – lower dose (e.g., 10‑20 mg alteplase) for patients at higher bleeding risk.
  3. Surgical embolectomy – reserved for contraindication to thrombolysis or massive clot burden.

D. Monitoring

• Admit to a monitored unit (step‑down or ICU).
• Continuous ECG, pulse oximetry, and frequent vitals (q15‑30 min initially).
• Serial troponin and BNP/NT‑proBNP every 6‑12 h to detect worsening RV strain.
• Repeat echocardiography within 24 h to assess RV size/function.

E. Transition to oral anticoagulation

• After 5‑7 days of LMWH (or UFH), switch to a direct oral anticoagulant (DOAC) – e.g., rivaroxaban 15 mg PO twice daily for 21 days, then 20 mg once daily.
• Duration: minimum 3 months; extended therapy considered if unprovoked or persistent risk factors.

F. Ancillary measures

• Compression stockings for DVT prophylaxis in the contralateral limb.
• Early ambulation as tolerated.

4. Further investigations

These investigations help refine prognosis, guide duration of anticoagulation, and detect underlying causes that may necessitate specific treatment (e.g., cancer therapy, lifelong anticoagulation for thrombophilia).

5. Complications and prevention

Preventive strategies focus on prompt diagnosis, risk‑adjusted anticoagulation, early mobilisation, and addressing modifiable risk factors (weight loss, smoking cessation). In selected high‑risk patients, mechanical prophylaxis (intermittent pneumatic compression) may be added during hospital stay.

Key learning points

• Sudden dyspnoea, pleuritic chest pain, and risk factors (immobility, obesity) should raise suspicion for PE.
• D‑dimer is highly sensitive but not specific; a markedly elevated value (> 0.5 µg/mL) warrants imaging in low‑intermediate pre‑test probability.
• CTPA remains the gold standard for confirming PE; lower‑limb Doppler identifies the thrombus source.
• ESC 2022 risk stratification separates patients into haemodynamic (high‑risk) and RV‑function/biomarker‑based (intermediate) categories, guiding intensity of monitoring and reperfusion decisions.
• Initial anticoagulation with LMWH (or UFH) should be started immediately; DOACs are preferred for long‑term therapy per ACCP 2023.
• Systemic thrombolysis is reserved for haemodynamically unstable patients; catheter‑directed therapy offers a lower bleeding risk alternative.
• Follow‑up imaging and assessment for underlying thrombophilia or occult malignancy are essential for secondary prevention.
• Long‑term complications include CTEPH, recurrent VTE, and post‑PE syndrome; early rehabilitation and risk‑factor modification reduce morbidity.

Practice MCQs

1. A 58‑year‑old man with acute PE is haemodynamically stable but has a troponin rise and RV dilatation on echo. According to ESC 2022, he belongs to which risk category?

A. Low‑risk
B. Intermediate‑low risk
C. Intermediate‑high risk
D. High‑risk

Answer: C — The presence of both RV dysfunction and myocardial injury in a haemodynamically stable patient classifies him as intermediate‑high risk.

2. Which of the following is the preferred initial anticoagulant for a patient with acute PE and normal renal function?

A. Unfractionated heparin infusion
B. Enoxaparin (LMWH) subcutaneously
C. Warfarin loading dose
D. Aspirin

Answer: B — LMWH (enoxaparin 1 mg/kg SC q12 h) is recommended as first‑line anticoagulation in acute PE with normal renal function (ACCP 2023, Grade 1A).

3. A patient with confirmed PE develops hypotension (SBP = 80 mm Hg) and signs of shock. The most appropriate immediate reperfusion therapy is:

A. Start high‑dose intravenous steroids
B. Systemic thrombolysis with alteplase 100 mg IV over 2 h
C. Immediate surgical embolectomy without thrombolysis
D. Increase LMWH dose to therapeutic level only

Answer: B — In high‑

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