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Massive PE Thrombolysis — RACP Adult Medicine MCQ

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EasyRespiratoryMassive PE ThrombolysisRACP Adult Medicine

A 55-year-old man presents with massive PE: acute dyspnoea, hypotension (BP 70/40 despite IV fluids), tachycardia (HR 130), and SpO₂ 82%. CTPA shows bilateral extensive PE with RV dilatation (RV:LV 1.5). He has no contraindications to thrombolysis. What is the most appropriate management?

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Correct answer: C — Systemic thrombolysis (alteplase 100 mg IV over 2 hours)

Massive PE (PE with sustained hypotension — sBP <90 for >15 minutes) is the ONLY PE severity where systemic thrombolysis is indicated. Alteplase 100 mg IV over 2 hours (or 0.6 mg/kg over 15 minutes if in cardiac arrest) reduces mortality by ~50%. Absolute contraindications are few in the context of life-threatening PE. UFH is given concurrently. Surgical embolectomy or catheter-based intervention is for patients with thrombolysis contraindications or failure.

Reference: ESC – 2019 – PE Guidelines; eTG Haematology 2024