Consideration for thrombolysis for significant pulmonary embolism in haemodynamically stable patients—is it time for a rethink?

Pulmonary embolism (PE) is a common diagnosis made in the emergency department with 60–70 cases per 100,000. The clinician needs to have up to-date knowledge and potential treatment strategies for management of this common condition. Thrombolysis for PE is one of the options that can be considered in the Emergency Department. The British Thoracic Society (BTS) has formed a set of recommendations for consideration of thrombolysis. We will discuss two clinical cases of differing severity and discuss the rationale behind the treatment strategies. Firstly, we present a lady in her late 40s with acute shortness of breath with pleuritic chest pain. She was brought in by ambulance and the resuscitation suite was pre-alerted that she was due to arrive. She had been recently treated for a lower limb deep venous thrombosis (DVT) and had presented to a local hospital 2/7 previously with some associated pleuritic chest pain. She was noted to be profoundly compromised from a cardiovascular perspective. She was treated with a systemic thrombolytic agent and she was subsequently discharged soon afterwards. The second case we present is that of a 50-year-old previously fit and well gentleman who presented with acute shortness of breath on minimal exertion for the previous 3 days. There was no background history of airway diseases with no smoking. He was noted to be marked hypoxic requiring 5 litres of oxygen to maintain an oxygen saturation of 95%. His blood pressure was noted to be stable throughout his time in the department. There was imaging and electrocardiographic evidence of right ventricular strain. It was also noted to be a marked rise in cardiac enzymes indicating cardiac involvement, based on the findings he subsequently underwent treatment with a systemic thrombolytic agent and made subsequently satisfactory recovery. The presence of raised troponin in the presence of an acute PE classifies as a massive PE. Systemic thrombolysis is the first line treatment for massive PE and should be started on clinical grounds alone if cardiac arrest in imminent with alteplase being the drug of choice. The decision to perform systemic thrombolysis in the haemodynamically stable patient is multifactorial and should be assessed in a case by case manner as highlighted by this article.