Acute pulmonary embolism (PE) is a major cause of cardiovascular mortality. Traditionally, management predominantly involves supportive therapy, anticoagulation, and monitoring(1).
It is recognised that right ventricular (RV) overload, decompensation, and failure drive cardiovascular death in PE. However, the deleterious effects of RV failure beyond mortality (symptomatic limitation, chronic thromboembolic pulmonary hypertension) are overlooked by traditional treatment algorithms(1). Systemic thrombolysis is reserved for those with haemodynamic compromise due to risks of major bleeding (~10%)(2); one previous trial in intermediate-risk PE reported a lower risk of haemodynamic compromise for systemic thrombolysis compared with anticoagulation, but with a five-fold increased risk of major bleeding(3).