[Thrombolysis in hemodynamically unstable patients with acute pulmonary embolism: searching for the optimal therapeutic temporal window]

Current guidelines on the management of acute pulmonary embolism (PE) of the European Society of Cardiology recommend the administration of systemic thrombolysis in hemodynamically unstable patients (defined as high risk - class I, level of evidence A). However, in the real world, systemic thrombolysis remains underused in hemodynamically unstable PE patients. We systematically reviewed and analyzed all studies published from 2008 to 2022 that evaluated the optimal therapeutic window for systemic thrombolysis in high-risk PE patients, also reporting potential thrombolysis-related adverse events. We identified only two studies enrolling 532 patients (mean age 65.5 years, 251 male). These studies suggested that early administration of systemic thrombolysis was associated with reduced short-term mortality and lower rates of major bleeding events and subsequent clinical deterioration. The identification of a less wide therapeutic window for the administration of systemic thrombolysis may improve the short-term mortality of high-risk PE patients and reduce the incidence of thrombolysis-related adverse events encouraging the use of systemic fibrinolysis, where appropriate.