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If we had robust evidence one way or the other to inform us on the use of thrombolytics in submassive pulmonary embolus (PE), we would not need this debate. But, we do not and, so, we do. The stakes are considered high both in favour and against thromobolysing submassive PE, so we cannot brush the debate under the carpet while we await the evidence. It is accepted that high-risk/massive PE, defined as haemodynamic instability, merits aggressive treatment due to unacceptable mortality, which outweighs the risk of haemorrhage. At the other end of the spectrum, patients with low-risk PE do not, such that they may even be treated as outpatients.
This leaves a grey area in between. When faced with a patient with a large thrombus load with a right ventricle (RV) that is dilated and pressure-loaded, but who is normotensive, as the attending clinician, we know they are at increased risk of death and long-term complications, such as chronic thromboembolic pulmonary hypertension (CTEPH).1 ,2 We may fall back on the Hippocratic Oath to ‘first, do no harm’, but the fuller translation reads ‘I will use treatments for the benefit of the ill in accordance with my ability and my judgment, but from what is to their harm and injustice I will keep them’. Thus, rather than hide behind a lack of evidence, we must review what we have and come to a balanced decision, and justify it.
In proposing the argument that submassive PE should be treated with thrombolysis, we must first accept that direct mortality due to the PE itself, not confounding conditions, remains unacceptably high with anticoagulation alone. A more aggressive strategy is required. As long as the benefits of thrombolysis outweigh the risks, then thrombolysis offers the best currently available approach. When …
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