Case Study: A 78-year-old male with a background medical history of hypertension presented to the emergency department with pleuritic chest pain and a 30-second episode of collapse. Further investigations revealed elevated d-dimer (>20 µg/mL), troponin (232 ng/L), and BNP (2644 ng/L) levels. A CT pulmonary angiogram (CTPA) showed extensive bilateral pulmonary emboli in the main pulmonary arteries, extending into the lobar and segmental pulmonary branches. The CTPA also revealed evidence of heart strain with a RV/LV ratio >1.0. On the basis of clinical and imaging parameters, the patient was categorised as having an intermediate-high risk pulmonary embolism.
Venous thromboembolism, comprising deep vein thrombosis (DVT) and pulmonary embolism (PE), is a leading cause of death in developed countries.1 PE can be lethal through a spiral of events culminating in right ventricular strain, right ventricular failure, systemic hypotension and cardiac failure.2 Assessment of PE severity is crucial when determining appropriate treatment options. High risk pulmonary embolism is defined by current European Society of Cardiology (ESC) guidelines by cardiac arrest or haemodynamic instability/ shock and is associated with very high mortality.2, 3 Patients with intermediate risk pulmonary embolism do not fulfil criteria for high-risk PE but may be very unwell, with right ventricular strain, elevated biomarkers of myocardial injury and a high “PE severity index”, which predicts early mortality.2
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