• Wendy Bottinor, Jeremy Turlington, Syed Raza, Charlotte S Roberts, Rajiv Malhotra, Ion S Jovin, and Antonio Abbate.
• Department of Internal Medicine (Drs. Bottinor and Turlington) and Department of Internal Medicine, Division of Pulmonary/Critical Care Medicine (Dr. Malhotra), Virginia Commonwealth University Health System; Pauley Heart Center Division of Cardiology (Drs. Abbate, Jovin, and Raza, and Ms Roberts); Richmond, Virginia 23298; and Division of Cardiology (Dr. Jovin), Hunter Holmes McGuire VA Medical Center, Richmond, Virginia 23249.
• Tex Heart Inst J. 2014 Apr 1;41(2):174-6.

AbstractMassive pulmonary embolism is associated with mortality rates exceeding 50%. Current practice guidelines include the immediate administration of thrombolytic therapy in the absence of contraindications. However, thrombolysis for pulmonary embolism is said to be absolutely contraindicated in the presence of recent hemorrhagic stroke and other conditions. The current contraindications to thrombolytic therapy have been extrapolated from data on acute coronary syndrome and are not specific for venous thromboembolic disease. Some investigators have proposed that the current contraindications be viewed as relative, rather than absolute, in cases of high-risk pulmonary embolism. We present the case of a 60-year-old woman in whom massive pulmonary embolism led to cardiac arrest with pulseless electrical activity. Eight weeks earlier, she had sustained a hemorrhagic cerebrovascular accident-a classic absolute contraindication to thrombolytic therapy. Despite this practice guideline, we administered tissue plasminogen activator systemically in order to save the patient's life. This therapy did not evoke intracranial bleeding, and the patient was eventually discharged from the hospital. Until guidelines specific to venous thromboembolic disease are developed, we think that the current contraindications to thrombolysis should be considered on an individual basis in patients who are at high risk of death from massive pulmonary embolism.

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