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Question 3#

A 32-year-old woman with a history of a ruptured ectopic pregnancy who underwent a laparoscopic salpingectomy 4 days ago presents to the hospital after 1 day of feeling short of breath. In the ED, her examination is significant for labored breathing and her vital signs show a heart rate of 105 bpm, blood pressure of 98/65 mm Hg, SpO2 of 88%, with respiratory rate of 22/min. Her chest X-ray is clear. Her laboratory test results are notable for a NT proBNP of 600 pg/mL and troponin I of 0.5 ng/mL. CT angiogram of her chest demonstrates large, central pulmonary embolus (PE), and RV/LV ratio of 1. You are called for admission to the ICU given the patient’s newly diagnosed PE.

Which of the following interventions is contraindicated in this patient? 

A. IVC filter
B. Heparin anticoagulation only
C. Directed catheter therapy
D. Systemic tPA

Correct Answer is D


Correct Answer: D

There are several risk stratification tools for patients presenting with an acute PE. Given patient’s relative hemodynamic stability (with a systolic blood pressure >90 mm Hg), her PE can be classified as submassive. Her elevated BNP, troponin, and RV/LV ratio greater than 0.9 are signs of RV dysfunction. She can thus be further classified as having an intermediatehigh risk PE.

Data surrounding treatment of submassive PEs are controversial. The decision of whether to administer systemic tPA in these patients should entail a discussion between care team members and the patient regarding the risks and benefits. Generally, however, recent surgery (defined as having surgery less than 3 weeks prior) is a contraindication to systemic tPA. 

Key point: Contraindications to systemic tPA include:


  1. ESC Committee for Practice Guidelines. 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolus: the task force for the diagnosis and management of acute pulmonary embolism of the European Society of Cardiology (ESC). Eur Heart J. 2014;35(43):3033-3073.
  2. Konstantinides SV, Barco S, Lankeit M, Meyer G. Management of pulmonary embolism: an update. J Am Coll Cardiol. 2016;67(8):976-990.