Pleuritic Pain, Tachycardia and a Positive D-dimer in a Young Woman
A 34-year-old woman with obesity (BMI 31 kg/m²) presents to the emergency department with 3 days of sharp right-sided pleuritic chest pain and breathlessness. She takes a combined oral contraceptive and has no prior venous thromboembolism, cancer, surgery or immobilization. Heart rate is 114 beats/min, blood pressure 118/74 mmHg, respiratory rate 24/min, temperature 36.8°C, and oxygen saturation 96% on room air. The chest radiograph is normal and the ECG shows sinus tachycardia. She has no calf tenderness. A quantitative D-dimer is 1.8 mg/L FEU (upper limit 0.5). Creatinine is normal, she is not pregnant, and she has no contrast allergy. The Wells score is calculated as 4.5 points. The emergency physician asks whether she can be discharged while awaiting imaging and what imaging should be arranged.
1. How should the Wells score and D-dimer be used here, and what is the next imaging step?
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A Wells score of 4.5 places her in the PE-likely category, usually defined as more than 4 points. In a PE-likely patient, a D-dimer should not be used to exclude the diagnosis, and the fact that it is elevated is nonspecific. The D-dimer is consistent with PE but also with infection, inflammation, pregnancy and many other states; it does not confirm PE. The clinical picture of pleuritic pain, tachycardia and estrogen exposure raises concern despite the normal chest radiograph.
The next step is CT pulmonary angiography, after checking renal function and contrast allergy, which are acceptable here. She should not be discharged while awaiting imaging because PE remains a plausible and potentially dangerous diagnosis. If CTPA is nondiagnostic and clinical suspicion remains high, perform venous ultrasound or a ventilation-perfusion scan, or repeat imaging according to local protocols. The PERC rule is not applicable because she has a positive dichotomized Wells score and tachycardia. The judgement point is that the D-dimer adds little after a likely Wells score; imaging, not serial D-dimers, should drive management.
2. CTPA confirms bilateral segmental pulmonary embolism with a normal right ventricular/left ventricular ratio; troponin and BNP are normal; sPESI is 1 because the heart rate is at least 110/min. How do you risk-stratify her and where should she be treated?
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She is not high-risk. She is hemodynamically stable, has normal ventricular function and normal cardiac biomarkers, so there is no indication for systemic thrombolysis or catheter-directed intervention. The sPESI of 1 places her in the intermediate-low-risk group rather than the low-risk group by that score, but the overall picture is reassuring. The heart-rate point is driven by pain and anxiety as well as PE, so it should not be interpreted in isolation.
Disposition should combine risk scores with clinical and social factors. She could be considered for early discharge or a short observation stay if she is stable, has adequate oxygenation, no severe pain, no active bleeding, normal renal function and reliable follow-up, and if a validated outpatient pathway such as HESTIA supports it. She should not be sent home without a clear anticoagulation plan, safety advice and a follow-up appointment. If there is any uncertainty about adherence, ongoing symptoms or social support, admit for observation. The common error is either over-treating a stable patient with thrombolysis or under-treating by discharging before anticoagulation and follow-up are arranged.
3. What anticoagulant and duration would you recommend, and what else must be addressed?
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A direct oral anticoagulant such as apixaban or rivaroxaban is a reasonable first choice in a stable patient without cancer, pregnancy, antiphospholipid syndrome or severe renal impairment. Warfarin is an alternative if a DOAC is unsuitable. If antiphospholipid syndrome is strongly suspected because of unusual thrombosis, recurrent events or autoimmune history, testing should be arranged before committing to a DOAC, because DOACs are less reliable in triple-positive antiphospholipid syndrome.
This event is provoked by combined oral contraceptive use. For a transient hormonal provocation, guidelines generally support at least 3 months of anticoagulation, with the decision about extended therapy based on residual risk, bleeding risk and patient preference. Estrogen-containing contraception should be stopped and replaced with a progestin-only method, levonorgestrel intrauterine device or barrier method after counselling. She should be advised about bleeding, pregnancy planning and the need to seek review before stopping anticoagulation. Routine thrombophilia testing is not indicated for a first provoked event unless there is a strong family history or another reason; testing during anticoagulation can also give misleading results. Document the shared decision and arrange follow-up to reassess duration.