Thrombolysis for hemodynamically stable pulmonary embolism: Time to close the book?

Abstract

Despite the lack of convincing evidence from large randomized controlled trials (RCT), thrombolytic treatment of patients with acute pulmonary embolism (PE) who are hemodynamically compromised is generally accepted and recommended in international guidelines [ 1 Kearon C. Akl E.A. Comerota A.J. Prandoni P. Bounameaux H. Goldhaber S.Z. et al. Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012; 141: e419S-e494S Crossref PubMed Scopus (2859) Google Scholar , 2 Konstantinides S.V. Torbicki A. Agnelli G. Danchin N. Fitzmaurice D. Galie N. et al. 2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism: The Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC) Endorsed by the European Respiratory Society (ERS). Eur Heart J. 2014; https://doi.org/10.1093/eurheartj/ehu283 Crossref Scopus (2144) Google Scholar ]. In contrast, the efficacy and safety of such treatment in hemodynamically stable PE patients with signs of right ventricular overload and/or myocardial damage referred to as “intermediate high risk” in the most recent ESC guidelines, has been debated for years because it has been shown that these findings are predictive factors for unfavorable clinical outcome of acute PE [ 2 Konstantinides S.V. Torbicki A. Agnelli G. Danchin N. Fitzmaurice D. Galie N. et al. 2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism: The Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC) Endorsed by the European Respiratory Society (ERS). Eur Heart J. 2014; https://doi.org/10.1093/eurheartj/ehu283 Crossref Scopus (2144) Google Scholar , 3 Lankeit M. Konstantinides S. Thrombolysis for pulmonary embolism: Past, present and future. Thromb Haemost. 2010; 103: 877-883 Crossref PubMed Scopus (39) Google Scholar ]. Until recently, this debate was restricted to the interpretation of extrapolated data from small uncontrolled studies in heterogeneous cohorts.