Acute Pulmonary Embolism (PE) with Hypotension (see Acute Pulmonary Embolism, [[Acute Pulmonary Embolism]])
Meta-Analysis of Thrombolyis in Acute PE (2014) [MEDLINE]: meta-analysis (16 trials, n = 2115)
Thrombolysis decreased mortality rate (2.17%), as compared to anticoagulation alone (3.89%)
No mortality benefit was observed in patients >65 y/o, a population in whom the risk of hemorrhage was greatest
Thrombolysis decreased the risk of recurrent PE (1.17%) as compared to anticoagulation alone (3.04%)
Thrombolysis increased the risk of major hemorrhage (9.2%), as compared to anticoagulation alone (3.4%)
No significant difference in major hemorrhage in patients 65 y/o and younger
Thrombolysis increased the risk of intracranial hemorrhage (1.5%), as compared to anticoagulation alone (0.2%)
PEITHO Trial (2014) [MEDLINE]: RCT of tenecteplase (n = 1006), intention-to-treat analysis in normotensive, intermediate-risk PE patients
Thrombolysis decreased hemodynamic decompensation (2.6%), as compared to placebo group (5.6%)
No difference in 30-day mortality rate
Thrombolysis increased risk of major hemorrhage and stroke
Chest Antithrombotic Therapy for VTE Disease 2016 Guidelines [MEDLINE]: thrombolytics are recommended (Grade 2B recommendation)
Systemic Therapy is Recommended Over Catheter-Directed Thrombolysis (Grade 2C recommendation): however, bleeding risk may indicate catheter-directed thrombolysis in centers where expertise is present
Systemic thrombolytics can also be considered in patient who deteriorate after starting anticoagulation (significant hypoxemia, poor tissue perfusion, etc), but who have not developed hypotension yet
