Background The management of intermediate-high risk acute pulmonary embolism (PE) is controversial with increasing interest in more aggressive treatment approaches than anticoagulation alone. Case summary We describe the case series of four consecutive patients who presented to emergency room for acute shortness of breath. They were diagnosed with intermediate-high risk acute PE based on the computed tomography pulmonary angiography (CTPA) and transthoracic echocardiography (TEE) findings and the elevated simplified pulmonary embolism score index (sPESI). They received bolus of 5 mg thrombolytics (rtPA) administered through peripheral intravenous line followed by continuous infusion at a rate of 2 mg per hour along with unfractionnated heparin at a rate of 500 mg/hour for additional ≤ 10 hours. There after the dose of UFH was increased to reach a therapeutic level. Rapid clinical improvement and also improvement in TTE parameters were noted at discharge. Patients were discharged home on oral anticoagulation. Discussion Intermediate high risk acute PE carries increased risk of mortality and morbidities. CDT uses a low rtPA dose for local thrombolysis and is associated with low bleeding risk; however it is expensive and requires expertise and human resources. Low dose rtPA through a peripheral IV-line might be safe and effective in the treatment of patient with intermediate-high risk acute PE. This therapeutic approach is readily available at most medical centers, can be started in the ER, and can be alternative to CDT nowadays during the COVID-19 era and in hospitals at the periphery and with limited resources.
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