What is the best initial management for an elderly female with a history of anxiety and pulmonary embolism (PE) presenting with tachycardia, hypertension, and a significant discrepancy in blood pressure readings between arms?

Management of Elderly Female with Tachycardia, Hypertension, and History of Pulmonary Embolism

The priority is to rule out recurrent pulmonary embolism given her history of PE, current tachycardia (98-128 bpm), and hypertension, as PE can present with tachycardia and compensatory hypertension before hemodynamic collapse; if PE is excluded, this represents asymptomatic hypertensive urgency requiring observation and gradual blood pressure reduction over 24-48 hours, not immediate aggressive treatment. 1, 2

Immediate Assessment for Pulmonary Embolism

The combination of tachycardia and history of PE is concerning for recurrent thromboembolism, as sustained tachycardia can be an ominous compensatory sign of right ventricular dysfunction preceding hemodynamic collapse. 3

• Obtain immediate ECG looking specifically for signs of acute pulmonary hypertension: S1Q3T3 pattern, T-wave inversions in V1-V4, incomplete right bundle branch block, or nonsinus rhythm, which occur more frequently in PE patients 4
• Check troponin and BNP/NT-proBNP for evidence of right ventricular strain 5
• Perform bedside echocardiography if available to assess for RV dysfunction 5
• If clinical suspicion remains moderate-to-high based on tachycardia and history, initiate anticoagulation immediately while diagnostic workup proceeds unless active bleeding exists 5

Blood Pressure Discrepancy Evaluation

The significant inter-arm blood pressure difference (28 mmHg systolic) requires attention, as guidelines recommend measuring both arms simultaneously at first visit and using the arm with higher readings for subsequent measurements. 6

• Remeasure blood pressure using validated automated upper arm cuff with appropriate cuff size 6
• Use the right arm (188/128 mmHg) for clinical decision-making going forward 6
• Inter-arm differences >15 mmHg may indicate vascular pathology, though this is not the immediate priority given PE history 6

Management Based on PE Status

If PE is Confirmed or Highly Suspected:

For hemodynamically stable patients (systolic BP ≥90 mmHg), initiate low-molecular-weight heparin or fondaparinux as preferred initial anticoagulation. 5

• The patient is NOT high-risk PE (no shock, systolic BP >90 mmHg), so thrombolysis is not indicated 1
• Continue parenteral anticoagulation for at least 5 days before transitioning to oral anticoagulation 5
• Transition to direct oral anticoagulant (rivaroxaban, apixaban, dabigatran, or edoxaban) rather than warfarin for long-term therapy 5

If PE is Excluded:

This represents hypertensive urgency (BP ≥180/120 mmHg without acute organ damage), which requires gradual blood pressure reduction over 24-48 hours, NOT aggressive acute lowering. 2

• The patient explicitly denies headache, visual changes, chest pain, or dyspnea—no evidence of hypertensive emergency 2
• Aggressive BP lowering should be avoided in urgencies; gradual reduction with oral medication over 24-48 hours is the appropriate approach 2
• Target reduction of 20-25% over 24-48 hours, not immediate normalization 2

Anxiety Consideration

While the patient has a history of anxiety, do not attribute tachycardia and hypertension solely to anxiety without excluding life-threatening causes, particularly recurrent PE given her history. 3

• Anxiety can cause both tachycardia and hypertension, but this is a diagnosis of exclusion 3
• Sustained tachycardia in the setting of previous PE warrants thorough evaluation before attributing symptoms to anxiety 3

Critical Pitfalls to Avoid

• Do not aggressively lower blood pressure in the emergency setting without evidence of acute end-organ damage (hypertensive emergency vs urgency distinction is critical) 2
• Do not dismiss tachycardia as anxiety-related without ruling out PE, as tachycardia may represent compensatory response to impending hemodynamic collapse 3
• Do not delay anticoagulation if PE suspicion is moderate-to-high while awaiting definitive imaging 5
• Do not use direct oral anticoagulants as initial therapy if PE is confirmed and patient requires immediate anticoagulation; parenteral agents are preferred initially 5, 7

Disposition Algorithm

If PE ruled out and patient remains asymptomatic: Observe in emergency department, initiate or adjust oral antihypertensive if not already on therapy (consider ACEI/ARB as first-line for elderly patient per ISH guidelines), arrange outpatient follow-up within 2-3 days for repeated BP measurements 6, 2

If PE confirmed: Admit for anticoagulation initiation and monitoring, as this represents recurrent VTE requiring hospitalization 5