Problem Issues of Diagnostic and Treatment of Pulmonary Embolism: a Case from Real Clinical Practice

Pulmonary embolism (PE) is a serious and life-threatening condition for the patient, which is mostly provoked by the presence of venous thrombosis of various localization. Among the numerous risk factors, the identification and study of which is still ongoing, an important place is the long-term immobile position of the patient during relocations or flights, which is particularly relevant for people whose professional activity is related to driving vehicles. Peculiarities of the course of PE in some cases require the adoption of non-standard decisions regarding the choice of antithrombotic therapy regimens, which allows maintaining a balance between the risks of thrombosis and bleeding. The experience of diagnostic search and subsequent use of systemic thrombolysis and heparin therapy in half doses as a compromise treatment regimen in a patient with PE of high intermediate risk and the presence of relative contraindications to intensive anticoagulation is presented. The article presents a clinical case of PE caused by venous thrombosis in a driver of a long-distance train, in whose therapy half-dose systemic thrombolysis was successfully used twice. The case demonstrates the polysyndromic nature of the clinical manifestations of PE, their mosaic nature, the need for an interdisciplinary approach to patient management, and vigilance regarding venous thromboembolism already at the early stages of the diagnostic search. Analyzing the above mentioned, it is necessary to remember that the clinical signs of PE can be masked by other cardiovascular, pulmonary, gastrointestinal, neurological diseases, hematological manifestations, which often leads to its late diagnosis, and, therefore, increases fatal risks. The etiologically and pathogenetically justified treatment of venous thromboembolism is therapy aimed at eliminating the thrombus (non-invasive or invasive) and preventing further thrombus formation. However, in the presence of a high risk of bleeding or relative contraindications to intensive anticoagulation, it is necessary to balance, choosing compromise treatment regimens. The presented clinical case of PE confirms the need for careful risk stratification, indicates the unpredictability of the course of venous thromboembolism and the related difficulties of diagnosis and selection of treatment management, which must be clearly individualized depending on the patient’s risks. The basis and powerful option for this are the Recommendations of the European Society of Cardiology (2014, 2019), the American Society of Hematology (2020), and the National Clinical Guidelines for the Management of Patients with Pulmonary Artery Thromboembolism (2017).