Patients and physicians are more likely to opt for clinical surveillance over anticoagulation if there is good cardiopulmonary reserve or a high risk of bleeding. Treatment of Acute PE Out of the Hospital *20. In patients with low-risk PE and whose home circumstances are adequate, we suggest treatment at home or early discharge over standard discharge (eg, after the rst 5 days of treatment) (Grade 2B). Systemic Thrombolytic Therapy for PE 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 systemically administered thrombolytic therapy (Grade 1B). *23. In selected patients with acute PE who deteri- orate 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). Remarks: Patients with PE and without hypotension who have severe symptoms or marked cardiopulmonary impairment should be monitored closely for deterioration. Development of hypotension suggests that 318 Evidence-Based Medicine [ 1 4 9 # 2 C H E S T F E B R U A R Y 2 0 1 6 ] thrombolytic therapy has become indicated. Cardiopulmonary deterioration (eg, symptoms, vital signs, tissue perfusion, gas exchange, cardiac biomarkers) that has not progressed to hypotension may also alter the risk-bene t assessment in favor of thrombolytic therapy in patients initially treated with anticoagulation alone. Catheter-Based Thrombus Removal for the Initial Treatment of PE *24. In patients with acute PE who are treated with a thrombolytic agent, we suggest systemic thrombo- lytic therapy using a peripheral vein over CDT (Grade 2C). 