Pulmonary embolism causing hemodynamic instability is termed massive; once itis suspected, a diagnostic plan and supportive measures are essential. Thephysiological effect of massive pulmonary embolism is such that resulting rightventricular failure may lead to compromised left ventricular preload, which maybe life-threatening
The most widely accepted indication for thrombolytic therapy is provenpulmonary embolism with cardiogenic shock; therapy is also frequentlyconsidered when a patient presents with systemic hypotension without shock.
The use of thrombolysis in submassive embolism
that is, pulmonary embolismcausing right ventricular dilatation and hypokinesis without systemichypotension is debated.Clinical trials have not been sufficiently large to providedefinitive data on the survival benefit in such cases
An elevated serum troponin level may identify a subgroup of normotensivepatients who may benefit from more aggressive treatment.
Thrombolytic therapy may also be considered in patients with severelycompromised oxygenation or a massive embolic burden identified by imagingstudies
even without hemodynamic instability
or in patients with extensivevenous thrombosis that accompanies nonmassive embolism. However, theevidence base supporting these indications is inadequate, and individualized careis necessary.TAPSON, V. F. N Eng J Med 2008; 358:1037-52