What is the first line of management for a patient presenting with dyspnea and evidence of right heart strain due to pulmonary embolism?

The first line of management for a patient presenting with dyspnea and evidence of right heart strain due to pulmonary embolism is thrombolytic therapy. This is best exemplified by administering alteplase, which is a fibrinolytic agent that promotes the dissolution of clots. In cases of massive pulmonary embolism where there is significant hemodynamic compromise and right heart strain, thrombolytics can restore blood flow rapidly, alleviate right ventricular pressure overload, and improve oxygenation.

Thrombolysis is particularly indicated when the patient's condition is critical or when there are signs of severe right ventricular dysfunction. Prompt administration in these cases can significantly reduce morbidity and mortality.

Other management strategies, such as diuretics, may be employed in cases of heart failure or fluid overload syndromes but do not address the underlying embolic event directly. Surgical thrombectomy is typically reserved for exceptional cases and is not the first-line treatment due to the invasiveness and potential complications. Beta-blockers, while useful in managing arrhythmias or some chronic conditions, are contraindicated in acute settings of hypotension or right heart strain due to pulmonary embolism as they can worsen hemodynamics and exacerbate right ventricular failure.