These patients need to be closely monitored to ensure that deteriorations are detected. Development of hypotension suggests that thrombolytic therapy has become indicated. Deterioration that has not resulted in hypotension may also prompt the use of thrombolytic therapy. For example, there may be a progressive increase in heart rate, a decrease in systolic BP (which remains >90 mm Hg), an increase in jugular venous pressure, worsening gas exchange, signs of shock (eg, cold sweaty skin, reduced urine output, confusion), progressive right heart dysfunction on echocardiography, or an increase in cardiac biomarkers. We do not propose that echocardiography or cardiac biomarkers are measured routinely in all patients with PE, or in all patients with a non low-risk PESI This is because, when measured routinely, the results of these assessments do not have clear therapeutic implications. For example, we do not recommend thrombolytic therapy routinely for patients without hypotension who have right ventricular dysfunction and an increase in cardiac biomarkers. However, we encourage assessment of right ventricular function by echocardiography and/or measurement of cardiac biomarkers if, following clinical assessment, there is uncertainty about whether patients require more intensive monitoring or should receive thrombolytic therapy. 21. In patients with acute PE associated with hypotension (eg, systolic BP < 90 mm Hg) who do not have a high bleeding risk, we suggest systemically administered thrombolytic therapy over no such therapy (Grade 2B). *22. In most patients with acute PE not associated with hypotension, we recommend against systemi- cally administered thrombolytic therapy (Grade 1B). *23. In selected patients with acute PE who deteriorate after starting anticoagulant therapy but have yet to develop hypotension and who have a low bleeding risk, we suggest systemically administered thrombolytic therapy over no such therapy (Grade 2C). 