Treatment of Submassive PE

A 67-year-old male patient with hypertension and chronic back pain saw his primary care physician for relatively new onset of shortness of breath. The patient first noticed these symptoms 1.5 weeks ago while doing regular household chores. The patient was a prior emergency medical technician and checked his vital signs. He was tachycardic (around 110 bpm) and had a blood pressure of 90/60 mmHg. Both findings were new for the patient. The patient denied ever having chest pain, peripheral edema, or fever. He works from home and sits most of the day. He is a life-long non-smoker. In the office, his blood pressure was 93/64 mmHg, his heart rate was 105 bpm, and his respiratory rate was 21 bpm with an O2 saturation of 97% on room air. There was a grade 2/6 holosystolic murmur best heard at the left lower sternal border and jugular venous distention slightly above the clavicle with the patient sitting upright. The lung fields were clear. An echocardiogram showed a right ventricular (RV) systolic pressure of 47 mmHg, with moderate tricuspid regurgitation and RV basal diameter of 53 mm. The patient was sent to the emergency department for further work-up, including a computed tomography pulmonary angiogram that revealed large emboli in both main pulmonary arteries with extension into the upper and lower lobes. Right to left ventricular dimension ratio on echocardiogram was 1.2. Troponin T was <0.02 ng/mL, B-type natriuretic peptide was 22 pg/mL, and creatinine was 1.3 mg/dL.

What is the best choice of treatment for this patient?

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