For hemodynamically stable pulmonary embolism, the standard initial management is?

• A. Anticoagulation
• B. Thrombolytics
• C. IVC filter
• D. Embolectomy

Answer: (A)

Anticoagulation is started promptly in a hemodynamically stable pulmonary embolism to prevent clot propagation and the formation of new clots, giving the body's natural fibrinolytic system time to break down the existing embolus. In stable patients, this approach effectively reduces the risk of deterioration without the bleeding risks associated with thrombolysis. The usual initial therapy is therapeutic anticoagulation with heparin (unfractionated or low-molecular-weight) and then a transition to an oral anticoagulant, typically a direct oral anticoagulant, for several months depending on the provoking factors.

Thrombolytics are reserved for massive PE with hemodynamic instability because they carry a substantial risk of major bleeding, including intracranial hemorrhage. An inferior vena cava filter is not first-line management unless anticoagulation cannot be started or is contraindicated, or in cases of recurrent PE despite adequate anticoagulation. Embolectomy is considered when there is urgent need for clot removal in unstable patients or when thrombolysis is contraindicated or unsuccessful.