Massive pulmonary embolism: what level of aggression?

Massive pulmonary embolism (PE) with hemodynamic instability (e.g., hypotension and cardiac shock) is associated with a poor prognosis and high mortality rates (> 50%). Accordingly patients with massive PE should be treated aggressively with thrombolytic agents (or surgical or interventional procedures). Streptokinase, urokinase, and recombinant tissue plasminogen activator (rtPA) have been used, with generally similar results. Among patients with submassive PE [i.e., subclinical right ventricular (RV) dysfunction and normal blood pressure], the role of thrombolytic therapy is controversial. Thrombolytic therapy is generally NOT indicated in normotensive patients without RV dysfunction. In this context, some experts recommend prompt administration of thrombolytic agents to prevent cardiogenic shock but data affirming benefit over heparin alone are lacking. Thrombolytic therapy is generally NOT indicated in normotensive patients without RV dysfunction. The role of echocardiography, computed tomographic (CT) scans, and cardiac biomarkers (e.g., troponins, brain natriuretic peptide, etc.) to identify patients who might benefit from aggressive thrombolytic therapy remains controversial. This article reviews indications for thrombolysis in massive PE, with an emphasis on recent data derived from normotensive patients. Further, we propose a diagnostic and therapeutic algorithm for treating acute PE. Additional studies are required to determine the benefit and safety of thrombolytic therapy for PE.