Thrombolysis is NOT administered to all patients with acute pulmonary embolism
Statement A is INCORRECT - thrombolysis is only administered to high-risk PE patients with hemodynamic instability, not to all patients with acute PE.
Evidence-Based Analysis
The 2019 ESC Guidelines 1 explicitly state that systemic thrombolytic therapy is recommended for high-risk PE (Class I, Level B), while routine use of primary systemic thrombolysis is NOT recommended in patients with intermediate- or low-risk PE (Class III, Level B). This is further supported by recent evidence 2 showing that systemic thrombolysis is reserved specifically for patients with systolic blood pressure lower than 90 mm Hg, where it provides an absolute mortality reduction of 1.6%.
Why the Other Statements Are Correct:
Statement B (CT pulmonary angiography): This is the standard diagnostic modality for confirming PE diagnosis 1, 2. CT angiography with contrast is the primary imaging test used in diagnostic algorithms.
Statement C (Elevated D-dimers): D-dimer testing is integral to PE diagnostic pathways 2. A D-dimer level <500 ng/mL in patients with low or intermediate clinical probability is associated with a posttest probability of PE less than 1.85%, allowing PE exclusion without imaging.
Statement D (Troponin and prognosis): Elevated cardiac biomarkers, including troponin, are used for risk stratification in intermediate-risk PE patients 1. These biomarkers help identify patients at higher risk for adverse outcomes and facilitate further risk stratification beyond clinical parameters.
Statement E (Malignancy association): PE commonly complicates malignant diseases. Cancer patients have significantly increased VTE risk, and PE management in cancer patients requires specific considerations 1.
Clinical Algorithm for Thrombolysis Decision:
- High-risk PE (hemodynamic instability/shock, SBP <90 mmHg): Systemic thrombolysis recommended 1
- Intermediate-risk PE (stable hemodynamics): Anticoagulation is standard; rescue thrombolysis only if hemodynamic deterioration occurs 1
- Low-risk PE: Anticoagulation only; thrombolysis contraindicated 1
Common Pitfall to Avoid:
Do not administer thrombolysis to hemodynamically stable patients with intermediate- or low-risk PE, as this increases bleeding risk without mortality benefit. The 2026 AHA/ACC guidelines 3 emphasize dynamic risk assessment, recognizing that clinical status may change, requiring serial reassessment rather than upfront aggressive therapy in stable patients.