Systemic thrombolysis

(EHJ 2020;41:543; Chest 2021;160:e545)

• Typically TPA 100 mg over 2h or wt-adjusted TNK bolus; risk of ICH ~2-5%, ↑ w/ age

• Consider if low bleed risk w/ acute PE + HoTN or cardiopulm deterioration after anticoag

• High-risk PE: ↓ death & recurrent PE each by ~50% (JAMA 2014;311:2414; EHJ 2015;36:605)

• Intermediate-risk PE: ↓ hemodyn decompensation, ↑ ICH & major bleeding, ↓ mortality in short- but not long-term; ? consider if <75 y and/or low bleed risk (JAMA 2014;311:2414)

• Half-dose lytic (50 mg or 0.5 mg/kg if <50 kg; 10-mg bolus → remainder over 2 h) in ~intermed. PE: ↓ pulm HTN & ? PE or death w/ ≈ bleeding vs. heparin alone (AJC 2013;111:273)

• DVT: consider if (a) acute (<14 d) & extensive (eg, iliofemoral), (b) severe sx swelling or ischemia, and (c) low bleed risk