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I would like to make some practical comments on and comparisons with the use of thrombolytic agents in acute myocardial infarction (MI), initially with regard to high-risk group patients who present with hemodynamic instability—systolic blood pressure (SBP) < 90 mmHg or a sustained ≥ 40-mmHg decrease in SBP for 15 minutes in the absence of other reasons, such as newonset arrhythmias, hypovolemia, or sepsis.(2) The use of thrombolytic agents in high-risk group patients has been reported to reduce the relative risk of death by 80%; however, according to one study, up to two thirds of such patients do not receive fi brinolytic agents.(3) This reduction in the relative risk of death is substantially larger than that observed in acute ST-segment elevation MI (STEMI), with ranges from 20-30%, according to one study.(4) Nevertheless, thrombolytic agents are widely used in acute STEMI, and not prescribing fi brinolytic therapy, especially when primary angioplasty is unavailable, is considered poor medical practice. I believe that the use of thrombolysis in high-risk PTE should be encouraged, provided that absolute contraindications are taken into account. Recently, a directive published in the Brazilian Offi cial Federal Government Journal(5) mandated that the indication for alteplase in treating PTE be incorporated into the Brazilian Unifi ed Health Care System. We should also be alert to the fact that several patients have borderline SBP (90-110 mmHg), and sometimes it is diffi cult to establish baseline blood pressure levels in order to determine whether there is a ≥ 40-mmHg decrease. In such cases, I recommend measuring serum lactate levels. Serum lactate levels > 2.0 mg/dL suggest that the observed blood pressure level is not adequate for tissue perfusion. If that is the case, the patient also meets the criteria for circulatory shock, since lactate levels are essential to detecting hemodynamic collapse. Some investigations have shown that lactate in this context is an independent predictor of mortality, being a better prognosticator than either troponin or N-terminal prohormone of brain natriuretic peptide (NT-proBNP). (6,7)

Use of thrombolytic agents in the treatment of acute pulmonary thromboembolism: things are not as simple as you might think