Patients with massive PE (i.e. persistent hypotension SBP <90 for ≥15 mins or requiring inotropic support) and acceptable risk of bleeding complications
Can be considered in initially hemodynamically stable patients (i.e. submassive PE) who acutely decompensate despite anticoagulation
develop persistent hypotension (massive PE)
increasing heart rate
JVD or worsening right heart failure
worsening gas exchange
signs of shock
develop persistent hypotension (massive PE)
increasing heart rate
JVD or worsening right heart failure
worsening gas exchange
signs of shock
See<unk><unk>  (PE)
Massive PE
Acute with
Sustained hypotension (systolic blood pressure <90 mm Hg for at least 15 minutes or requiring inotropic support, not due to a cause other than PE, such as arrhythmia, hypovolemia, sepsis, or left ventricular [LV] dysfunction) - ACCP 2016
Other definitions include pulselessness or persistent profound bradycardia (heart rate <40 bpm with signs or symptoms of shock)
Submassive PE
Acute without systemic hypotension (see above) but with either RV dysfunction or myocardial necrosis
RV dysfunction means the presence of at least 1 of the following:
RV dilation (apical 4-chamber RV diameter divided by LV diameter >0.9) or RV systolic dysfunction on echocardiography
RV dilation (4-chamber RV diameter divided by LV diameter >0.9) on CT
Elevation of BNP (>90 pg/mL)
Elevation of N-terminal pro-BNP (>500 pg/mL); or
Electrocardiographic changes (new complete or incomplete right bundle-branch block, anteroseptal ST elevation or depression, or anteroseptal T-wave inversion)
Myocardial necrosis is defined as either of the following:
Elevation of troponin I (>0.4 ng/mL) or
Elevation of troponin T (>0.1 ng/mL)
Acute with
Sustained hypotension (systolic blood pressure <90 mm Hg for at least 15 minutes or requiring inotropic support, not due to a cause other than PE, such as arrhythmia, hypovolemia, sepsis, or left ventricular [LV] dysfunction) - ACCP 2016
Other definitions include pulselessness or persistent profound bradycardia (heart rate <40 bpm with signs or symptoms of shock)
Sustained hypotension (systolic blood pressure <90 mm Hg for at least 15 minutes or requiring inotropic support, not due to a cause other than PE, such as arrhythmia, hypovolemia, sepsis, or left ventricular [LV] dysfunction) - ACCP 2016
Other definitions include pulselessness or persistent profound bradycardia (heart rate <40 bpm with signs or symptoms of shock)
Acute without systemic hypotension (see above) but with either RV dysfunction or myocardial necrosis
RV dysfunction means the presence of at least 1 of the following:
RV dilation (apical 4-chamber RV diameter divided by LV diameter >0.9) or RV systolic dysfunction on echocardiography
RV dilation (4-chamber RV diameter divided by LV diameter >0.9) on CT
Elevation of BNP (>90 pg/mL)
Elevation of N-terminal pro-BNP (>500 pg/mL); or
Electrocardiographic changes (new complete or incomplete right bundle-branch block, anteroseptal ST elevation or depression, or anteroseptal T-wave inversion)
Myocardial necrosis is defined as either of the following:
Elevation of troponin I (>0.4 ng/mL) or
Elevation of troponin T (>0.1 ng/mL)
RV dysfunction means the presence of at least 1 of the following:
RV dilation (apical 4-chamber RV diameter divided by LV diameter >0.9) or RV systolic dysfunction on echocardiography
RV dilation (4-chamber RV diameter divided by LV diameter >0.9) on CT
Elevation of BNP (>90 pg/mL)
Elevation of N-terminal pro-BNP (>500 pg/mL); or
Electrocardiographic changes (new complete or incomplete right bundle-branch block, anteroseptal ST elevation or depression, or anteroseptal T-wave inversion)
Myocardial necrosis is defined as either of the following:
Elevation of troponin I (>0.4 ng/mL) or
Elevation of troponin T (>0.1 ng/mL)
RV dilation (apical 4-chamber RV diameter divided by LV diameter >0.9) or RV systolic dysfunction on echocardiography
RV dilation (4-chamber RV diameter divided by LV diameter >0.9) on CT
Elevation of BNP (>90 pg/mL)
Elevation of N-terminal pro-BNP (>500 pg/mL); or
Elevation of troponin I (>0.4 ng/mL) or
Elevation of troponin T (>0.1 ng/mL)
Thrombolytics for pulmonary embolism
Thrombolytics for STEMI
Thrombolytics for acute ischemic stroke
Balloon tamponade for massive GI bleeding
Resuscitative endovascular balloon occlusion of the aorta
Anti-platelet agent reversal
Cardiovascular antibiotics
Formal echocardiography