An additional nding was that rescue thrombolytic therapy appeared to be of bene t in patients who developed cardiovascular collapse after initially being treated with anticoagulant therapy alone. Management Implication of the Updated Evidence: The improved quality of evidence has not resulted in substantial changes to our recommendations because: (1) the new data support that the bene ts of systemic thrombolytic therapy in patients without hypotension, including those with right ventricular dysfunction or an increase in cardiac biomarkers ( intermediate-risk PE ), 340 Evidence-Based Medicine [ 1 4 9 # 2 C H E S T F E B R U A R Y 2 0 1 6 ] are largely offset by the increase in bleeding; and (2) among patients without hypotension, it is still not possible to con dently identify those who will derive net bene t from this therapy. PE With Hypotension: Consistent with AT9, we suggest that patients with acute PE with hypotension (ie, systolic BP <90 mm Hg for 15 min) and without high bleeding risk (Table 15) are treated with thrombolytic therapy. The more severe and persistent the hypotension, and the more marked the associated features of shock and myocardial dysfunction or damage, the more compelling the indication for systemic thrombolytic therapy. Conversely, if hypotension is transient or less marked, not associated with features of shock or myocardial dysfunction, and if there are risk factors for bleeding, physicians and patients are likely to initially choose anticoagulant therapy without thrombolytic therapy. If thrombolytic therapy is not used and hypotension persists or becomes more marked, or clinical features of shock or myocardial damage develop or worsen, thrombolytic therapy may then be used. 