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Rescue Thrombolysis for PE — EECC MCQ

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ModeratePulmonary Vascular DiseaseRescue Thrombolysis for PEEECC

A 55-year-old woman with intermediate-risk PE (haemodynamically stable but RV dysfunction on echo and elevated troponin) deteriorates at 24 hours with new hypotension (SBP 85 mmHg). What rescue therapy is indicated?

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Correct answer: A — Systemic thrombolysis with alteplase 100 mg IV over 2 hours or tenecteplase weight-adjusted single bolus — rescue thrombolysis is indicated for haemodynamically unstable PE (Class I) even in initially intermediate-risk patients who deteriorate

Initial intermediate-risk PE (RV dysfunction + biomarker elevation but haemodynamically stable) is managed with anticoagulation and close monitoring. If haemodynamic deterioration occurs (new hypotension, shock), the patient reclassifies to high-risk/massive PE, and rescue systemic thrombolysis becomes a Class I indication. The ESC 2019 PE Guidelines recommend: (1) alteplase 100 mg IV over 2 hours (standard regimen); OR (2) tenecteplase weight-adjusted single IV bolus (more practical). If thrombolysis fails or is contraindicated, rescue options include catheter-directed therapy or surgical embolectomy. The PEITHO trial showed that routine thrombolysis in intermediate-risk PE reduces haemodynamic deterioration but increases major bleeding and stroke — hence it is reserved as rescue therapy rather than routine.

Reference: ESC (2019): Guidelines on Acute Pulmonary Embolism; PEITHO Trial