Anticoagulate with LMWH, IV/Sub-Q UFH, or fondaparinux (IA)

While working up PE, if pretest is moderate or high, and there are no contra-indications, start anticoagulation during the work-up (IC)


Definition of Massive PE-Acute PE with sustained hypotension (systolic blood pressure <90 mm Hg for at least 15 minutes or requiring inotropic support, not due to a cause other than PE, such as arrhythmia, hypovolemia, sepsis, or left ventricular [LV] dysfunction), pulselessness, or persistent profound bradycardia (heart rate <40 bpm with signs or symptoms of shock).

Definition of Submassive PE-Acute PE without systemic hypotension (systolic blood pressure >90 mm Hg) but with either RV dysfunction or myocardial necrosis.

  • RV dysfunction means the presence of at least 1 of the following:
    • —RV dilation (apical 4-chamber RV diameter divided by LV diameter >0.9) or RV systolic dysfunction on echocardiography

    • —RV dilation (4-chamber RV diameter divided by LV diameter >0.9) on CT

    • —Elevation of BNP (>90 pg/mL)

    • —Elevation of N-terminal pro-BNP (>500 pg/mL); or

    • —Electrocardiographic changes (new complete or incomplete right bundle-branch block, anteroseptal ST elevation or depression, or anteroseptal T-wave inversion)

  • Myocardial necrosis is defined as either of the following:
    • —Elevation of troponin I (>0.4 ng/mL) or

    • —Elevation of troponin T (>0.1 ng/mL)


Fibrinolysis is reasonable for pts with massive PE and acceptable risk of bleeding complications (IIa/B)

Fibrinolysis may be considered for pts with submassive PE judged to have clinical evidence of adverse prognosis (hemodynamic instability, worsening resp. insufficiency, severe RV dysfunction, or major myocardial necrosis) and low risk of bleeding complications (IIb/C)

Fibrinolysis is not recommended for patients with submassive PE with only mild dysfunction, i.e. low risk PEs (III/B)

Fibrinolysis is not recommended for undifferentiated cardiac arrest (III/B)

Interventional and Surgical Options

Either catheter embolectomy or surgical embolectomy can be considered depending on institutional and operator preference (IIa/C)

Either of these are reasonable if the pt is still unstable in massive PE after fibrinolysis (IIa/C)

Also reasonable in massive PE, if the pt has a contra-indication to lysis (IIa/C)

May be considered in lieu of fibrinolysis in patients with submassive PE and evidence of adverse prognosis (IIb/C)

Not recommended for pts with PE at low risk (III/C)


Contraindications to Fibrinolysis

Absolute contraindications include

  • any prior intracranial hemorrhage,
  • known structural intracranial cerebrovascular disease (eg, arteriovenous malformation),
  • known malignant intracranial neoplasm,
  • ischemic stroke within 3 months,
  • suspected aortic dissection,
  • active bleeding or bleeding diathesis,
  • recent surgery encroaching on the spinal canal or brain, and
  • recent significant closed-head or facial trauma with radiographic evidence of bony fracture or brain injury.

Relative contraindications include

  • age >75 years;
  • current use of anticoagulation;
  • pregnancy;
  • noncompressible vascular punctures;
  • traumatic or prolonged cardiopulmonary resuscitation (>10 minutes);
  • recent internal bleeding (within 2 to 4 weeks);
  • history of chronic, severe, and poorly controlled hypertension;
  • severe uncontrolled hypertension on presentation (systolic blood pressure >180 mm Hg or diastolic blood pressure >110 mm Hg);
  • dementia;
  • remote (>3 months) ischemic stroke; and
  • major surgery within 3 weeks.

Recent surgery, depending on the territory involved, and minor injuries, including minor head trauma due to syncope, are not necessarily barriers to fibrinolysis.

The clinician is in the best position to judge the relative merits of fibrinolysis on a case-by-case basis.


Further on who should get lytics

It is preferable to confirm the diagnosis of PE with imaging before fibrinolysis is initiated. When direct imaging is unavailable or unsafe because of the patient’s unstable condition, an alternative approach favors aggressive early management, including fibrinolysis, of the patient with sustained hypotension (systolic blood pressure <90 mm Hg for at least 15 minutes or requiring inotropic support, not clearly due to a cause other than PE) when there is a high clinical pretest probability of PE and RV dysfunction on bedside transthoracic echocardiography.We do not endorse the strategy of treating subjects with undifferentiated cardiac arrest with fibrinolysis, because this approach lacks clinical benefit.

 PE Fibrinolytic Treatment Algorithm

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