Treatment of Submassive Pulmonary Embolism: Knowing When to be Aggressive and When to be Conservative

A patient who presents with pulmonary embolism (PE) but without hypotension should undergo risk stratification with echocardiography, computed tomography, and serum biomarker assessment. Submassive PE is identified by the findings of right ventricular dysfunction by physical examination or imaging, or by elevations in serum troponin or brain-type natriuretic peptide in the context of acute PE. Evidence of cardiac strain should prompt evaluation by a multidisciplinary team with experience in the management of submassive PE. Consideration of therapies beyond systemic anticoagulation, such as systemic intravenous thrombolysis, catheter-directed thrombolysis, and percutaneous or surgical embolectomy, must be based on the clinical presentation, the risk of adverse outcome, the skill of the operator, and the bleeding risk. Here, we address the current understanding of submassive PE, new insights into how established therapies alter the natural history of the disease process, and recent advances in treatment options.