What are the contraindications for thrombolysis in patients with pulmonary embolism?

Contraindications for Thrombolysis in Pulmonary Embolism

In high-risk PE with shock or persistent hypotension, most contraindications become relative rather than absolute, and thrombolysis should be administered unless there is active bleeding or recent hemorrhagic stroke. 1, 2

Absolute Contraindications

The following are considered absolute contraindications in most clinical contexts 1, 2:

• Hemorrhagic stroke or stroke of unknown origin at any time - This remains an absolute contraindication even in life-threatening PE 1, 2
• Ischemic stroke within the preceding 6 months 1, 2
• Central nervous system damage or neoplasms 1, 2
• Recent major trauma, surgery, or head injury within the preceding 3 weeks 1, 2
• Gastrointestinal bleeding within the last month 1, 2
• Known active bleeding disorder 1, 2

Relative Contraindications

These contraindications require careful risk-benefit assessment, particularly in high-risk PE 1, 2:

• Transient ischemic attack in preceding 6 months 1, 2
• Current oral anticoagulant therapy 1, 2
• Pregnancy or within 1 week postpartum 1, 2
• Non-compressible vascular punctures 1, 2
• Traumatic cardiopulmonary resuscitation 1, 2
• Refractory hypertension (systolic blood pressure >180 mmHg) 1, 2
• Advanced liver disease 1, 2
• Infective endocarditis 1, 2
• Active peptic ulcer disease 1, 2

Critical Context: High-Risk vs. Non-High-Risk PE

The severity of PE fundamentally changes how contraindications are interpreted 1:

High-Risk PE (Shock/Persistent Hypotension)

• Contraindications that are absolute in acute myocardial infarction (such as surgery within 3 weeks or GI bleeding within the last month) become relative in immediately life-threatening high-risk PE 1, 2
• The survival benefit of thrombolysis in hemodynamically unstable patients outweighs most bleeding risks 1, 3
• Thrombolysis should be administered unless there are very few absolute contraindications (primarily active hemorrhage or recent hemorrhagic stroke) 1, 3

Intermediate-Risk PE (RV Dysfunction Without Shock)

• Standard contraindications apply more strictly 1
• Thrombolysis may be considered in selected patients without contraindications, but routine use is not recommended 1
• The bleeding risk (13% major bleeding, 1.8% intracranial/fatal hemorrhage) must be carefully weighed against uncertain benefit 1

Low-Risk PE

• Thrombolysis is contraindicated and should not be used 1

Bleeding Risk Considerations

Major bleeding occurs in approximately 13% of patients receiving thrombolysis, with intracranial or fatal hemorrhage in 1.8% 1. Risk factors that increase bleeding complications include 1, 4:

• Recent surgery (within 7 days)
• History of peptic ulcer disease or GI/urinary tract bleeding
• Platelet count <150 × 10⁹/L
• Invasive vascular procedures within 7 days
• Prolonged cardiopulmonary resuscitation

Alternative Strategies When Thrombolysis is Contraindicated

When absolute contraindications exist in high-risk PE 1, 2, 5:

1. Surgical pulmonary embolectomy is the preferred alternative 1, 2
2. Catheter-based embolectomy or thrombus fragmentation may be considered if surgery is not immediately available 1, 2, 5
3. Low-dose prolonged thrombolysis (e.g., urokinase 1,000 units/kg/h) has been reported as an alternative when standard doses are contraindicated, though this is not guideline-recommended 6

Important Caveats

• Recent thrombolysis is not a contraindication to surgical embolectomy if thrombolysis fails 1
• Angiographic confirmation is no longer required before thrombolysis and actually increases bleeding complications 1
• In pregnancy, thrombolysis is appropriate for massive PE but contraindicated within 6 hours of delivery due to extreme bleeding risk 1
• The choice between alteplase, tenecteplase, or catheter-directed therapy should favor alteplase in standard dosing (100 mg over 2 hours) as it shows lower major bleeding rates compared to tenecteplase or catheter-directed approaches 7