Thrombolytics in PE

Last night, I had a patient present with acute dyspnea, tachy in the 150s.  She had a h/o prior PE 5 years ago that she completed anticoagulation for.  EKG shown below has some TWI in anteroinferior leads (c/w RHS), and a nice Q wave in III (not really an S1, but impressive Q3T3).

Patient was started on a heparin ggt even prior to CT (slice shown below).  Bedside echo also revealed enlarged RV.  She had b/l PEs.  She was hemodynamically stable, so this was considered a submassive PE.

It got me thinking whether this patient may be a good candidate for thrombolyis as she is likely to have significant morbidity from her PEs.

Here's a quick summary of the major articles addressing this topic.  The best trials that I'm aware of on this question are MOPETT, PEITHO, and TOPCOAT (Klein's study).  See these posts:

http://www.emlitofnote.com/2013/01/mopett-half-dose-tpa-for-pe.html
http://www.emlitofnote.com/2014/04/a-positive-primary-outcome-for-peitho.html
http://www.emlitofnote.com/2014/07/dueling-pe-meta-analyses.html
http://www.ncbi.nlm.nih.gov/pubmed/24484241
http://emnerd.com/tag/interact2/

MOPETT: This one was interesting because they used a so-called "safe dose" of tPA - that is, half dose (50 mg for patient's > 50 kg).  They found improved rates of the composite outcome of recurrent PE and pulmonary hypertension.  No significant bleeding observed.

PEITHO: In this study, patients were randomized to tenecteplase and heparin vs placebo and heparin.  There was a benefit in the composite outcome of death or hemodynamic compromise in the thrombolytic group, but it was offset by the increased rate of hemorrhagic stroke.

TOPCOAT: This study was curiously terminated early because the primary author changed jobs.  They randomized patients to tenectaplase and LMWH vs tenectaplase and placebo.  The composite primary outcome was a bit much to follow but included death, shock, intubation, major bleeding, recurrent PE, and poor functional capacity.  There was a statistical benefit in the thrombolysis group.

There's actually an ACEP clinical policy on this subject also.  At the time of it's writing in 2011, there were 11 randomized trials evaluating thrombolytics in PE that are described in the policy.  The policy states "At this time, there is insufficient evidence to make any recommendations regarding use of thrombolytics in any subgroup of hemodynamically stable patients. Thrombolytics have been demonstrated to result in faster improvements in right ventricular function and pulmonary perfusion, but these benefits have not translated to improvements in mortality."

The patient was admitted to the ICU, and thrombolysis was held (at least for the moment).  Given the literature above, I think the treating physicians would have been justified either way.