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Fibrinolytic (thrombolytic) therapy in acute pulmonary embolism and lower extremity deep vein thrombosis

Victor F Tapson, MD
Section Editor
Jess Mandel, MD
Deputy Editors
Geraldine Finlay, MD
Susanna I Lee, MD, PhD


Thrombolytic agents activate plasminogen to form plasmin, resulting in the accelerated lysis of thrombi. As a result, thrombolytic agents have been used in a variety of thrombotic disorders including acute myocardial infarction, stroke, acute pulmonary embolism (PE), and deep vein thrombosis (DVT).

The indications, contraindications, adverse effects, and outcomes of thrombolytic therapy in acute PE and DVT are discussed here. In addition, the types of thrombolytic agents and regimens are reviewed. Alternative treatment modalities and anticoagulation for acute PE and DVT are discussed elsewhere. (See "Treatment, prognosis, and follow-up of acute pulmonary embolism in adults" and "Overview of the treatment of lower extremity deep vein thrombosis (DVT)" and "Venous thromboembolism: Initiation of anticoagulation (first 10 days)".)


Evidence from randomized and retrospective observational studies in patients with acute pulmonary embolism (PE) indicates that thrombolytic therapy leads to early hemodynamic improvement, but at a cost of increased major bleeding. The effect of thrombolytic therapy on mortality and the frequency of recurrent thromboembolism remain questionable. (See 'Outcomes' below.)

Typically, only patients in whom the diagnosis of acute PE has been confirmed should be considered for thrombolytic therapy because the adverse effects can be devastating. For each patient, the indications and potential benefits must be carefully weighed against the risk of adverse events, taking into consideration the patient's values and preferences. (See 'Indications' below.)

Indications — Persistent hypotension or shock (ie, a systolic blood pressure <90 mmHg or a decrease in the systolic blood pressure by ≥40 mmHg from baseline) due to acute PE is the only widely accepted indication for systemic thrombolysis [1]. In most cases, systemic thrombolytic therapy should be considered only after acute PE has been confirmed because the adverse effects of this therapy can be severe. Because a pulmonary arteriogram immediately precedes catheter-based therapy, PE can be confirmed at that time when this procedure is undertaken.


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Literature review current through: Mar 2017. | This topic last updated: Apr 21, 2017.
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