USMLE Prep - Medical Reference Library

Pulmonary Embolism with RV Strain — Risk Stratification and Reperfusion Pathways

System: Pulmonology • Reviewed: Aug 31, 2025 • Step 1Step 2Step 3

Synopsis:

Use clinical scores, cardiac biomarkers, and echocardiography/CT to identify intermediate-high risk PE with right ventricular dysfunction; consider systemic thrombolysis or catheter-directed therapy in select deteriorating patients; anticoagulate all unless contraindicated.

Key Points

  • Stabilize ABCs; treat life‑threatening derangements immediately.
  • Confirm diagnosis early with highest‑yield imaging/labs.
  • Initiate guideline‑based therapy and escalate by response.
  • Plan disposition and follow‑up explicitly.

Clinical Synopsis & Reasoning

Intermediate‑high risk PE features RV strain and positive biomarkers without sustained hypotension. Anticoagulate all patients. Escalate to systemic thrombolysis for decompensation or refractory shock if bleeding risk permits; consider catheter‑directed thrombolysis/thrombectomy in experienced centers. Engage a PE response team when available.

Treatment Strategy & Disposition

Intermediate‑high risk PE features RV strain and positive biomarkers without sustained hypotension. Anticoagulate all patients. Escalate to systemic thrombolysis for decompensation or refractory shock if bleeding risk permits; consider catheter‑directed thrombolysis/thrombectomy in experienced centers. Engage a PE response team when available.

Epidemiology / Risk Factors

  • Risk varies by comorbidity and precipitating factors

Initial Targets

ParameterTarget/Action
HemodynamicsMaintain perfusion; avoid hypotension
MonitoringSerial exam, labs, and imaging
TherapyStart early, reassess, de‑escalate when appropriate

Investigations

TestRole / RationaleTypical FindingsNotes
CBCScreen leukocytosis/anemiaContext‑specificTrend response
BMPElectrolytes/renal functionDerangements commonReplace K+/Mg2+
Key imagingCondition‑specific (CTA/MRI/Endoscopy)See textDo not delay when red flags

Pharmacology

MedicationMechanismOnsetRole in TherapyLimitations
Heparin (IV) or DOACAnticoagulantImmediateAll unless contraindicatedTransition per guideline
Alteplase (systemic)ThrombolyticMinutesHigh risk or deteriorationICH risk; strict selection

Prognosis / Complications

  • Outcome depends on timeliness of diagnosis and definitive therapy

Patient Education / Counseling

  • Explain red flags, adherence, and follow‑up plan

References

  1. 2019 ESC PE Guideline — Link
  2. ESC PE Guideline PDF — Link