A 37-year-old man with no past history of interest comes to the emergency department for syncope while walking. He had started two days earlier with dyspnea on exertion. Examination: weight 75 kg, BP 75/50 mm Hg. SatO2 89%. Pulmonary auscultation was normal. Cardiac auscultation: rhythmic tachycardic tones at 130 bpm. Abdomen normal. Extremities: no alterations. Normal hemogram. Troponin 1.2 ng / ml. ECG: Sensual tachycardia at 130 bpm. Inverted T in V1-V4. Thoracic CT angiography: repletion defect in both main pulmonary arteries. One hour after arrival at the emergency room, BP 70/55 mm Hg persists. What would be the most appropriate initial treatment?
The clinical case is a typical pulmonary thromboembolism. In this case it is associated with persistent arterial hypotension. Option 2 would be correct if the patient were not hypotensive. Option 3 is not correct since diagnostic confirmation is not necessary to initiate anticoagulant therapy in case of PTE without hypotension. Option 4 is not indicated. Option 5 would be correct only if the patient had a contraindication to fibrinolysis. Persistent hypotension in PTE is the most widely accepted indication for fibrinolysis, so the correct option is 1.
Unfractionated heparin, 10,000U iv on clinical suspicion. Fibrinolysis with tPA 100 mg iv once the diagnosis is confirmed.
Enoxaparin: 80 mg sc every 12 hours, starting upon diagnostic suspicion.
Enoxaparin; 80 mg sc every 12 hours, starting upon diagnostic confirmation.
Fondaparinux: 7.5 mg sc daily.
Emergency pulmonary thromboendarterectomy.
Persistent hypotension in PTE is the most widely accepted indication for fibrinolysis, so the correct option is 1.
Option 2 would be correct if the patient were not hypotensive.
Option 3 is not correct since diagnostic confirmation is not necessary to initiate anticoagulant therapy in case of PTE without hypotension.
Option 4 is not indicated.
Option 5 would be correct only if the patient had a contraindication to fibrinolysis.