The Bottom Line: Thrombolysis may be considered in selected intermediate-risk PE patients who have evidence of RV dysfunction or myocardial damage or in PE who may be clinically worsening or not improving with anticoagulation, and/or based on patient values or physician experience. Clinical benefit-to-risk profile is likely better for younger (<65 y/o) patients.
Reference: Chatterjee S, Chakraborty A, Weinberg I, Kadakia M, et al. Thrombolysis for pulmonary embolism and risk of all-cause mortality, major bleeding, and intracranial hemorrhage: a meta-analysis. JAMA. 2014 Jun 18;311(23):2414-2421. doi.10.1001/jama.2014.5990.
Summary: A meta-analysis of RCT findings concluded that among patients with pulmonary embolism, including those who were hemodynamically stable with right ventricular dysfunction, thrombolytic therapy was associated with lower rates of all-cause mortality and increased risks of major bleeding and ICH. However, findings may not apply to patients with pulmonary embolism who are hemodynamically stable without right ventricular dysfunction (Chatterjee et al, 2014).
Below is a table summarizing the evidence presented in the referenced meta-analysis (table created by Dr. Dan Dressler).
*Net Clinical Benefit = lives saved compared with ICH events (weighted 0.75 events per death event), intermediate-risk patients