A 60-year-old female with a past medical history of obesity with associated obstructive sleep apnea, compliant with CPAP therapy, presents to the emergency department with worsening shortness of breath over the past three days. She states that she has also noted increased bilateral lower extremity edema. On examination, she has a temperature of 99 Farenheit, a blood pressure of 100/70 mmHG, a heart rate of 120 beats per minute, respiratory rate of 19 breaths per minute, and oxygen saturation is 91% on 5 litres of oxygen via nasal cannulae. She is placed on IV heparin, and a CT angiogram (CTA) chest, venous Doppler, and echocardiogram are ordered. The CTA reveals the findings seen here. Additionally a right ventricular/left ventricular (RV/LV) ratio of 1.3 is noted, with contrast reflux into the inferior vena cava.
What would be the most appropriate treatment strategy in this patient at this time?
A.Observe, escalate to non-rebreather mask, continue anticoagulation
B.Intubate, aggressive IV fluids with 0.9 NS, send for right heart catheterization
C.Escalate for catheter-based therapy
D.Intravenous alteplase 100 mg immediately