Impact of Immediate Treatment on Acute Pulmonary Embolism in Patients with Hemodynamic Instability

Aims: This systematic review aims to evaluate the clinical outcomes, mortality, and safety profile of immediate therapeutic interventions—including systemic thrombolysis, surgical embolectomy, and catheter-directed therapies—for acute pulmonary embolism (APE) in adult patients presenting with hemodynamic instability. It also assesses the timing of interventions and outcomes across specific subgroups, such as elderly and comorbid patients. Study Design: Systematic literature review. Place and Duration of Study: Databases searched (PubMed, SciELO, LILACS, BVS, MEDLINE) between January 2014 and April 2024. Methodology: The review followed PRISMA guidelines. Studies published from 2014 to 2024 were included if they evaluated immediate treatment strategies in adult patients with high-risk APE and hemodynamic instability. Eligible study designs included randomized clinical trials, cohort studies, and multicenter analyses. Data extraction and quality assessment (using the Newcastle-Ottawa Scale and Cochrane RoB 2.0 tool) were performed independently by two reviewers. Results: Of 487 studies identified, 32 met all inclusion criteria, encompassing 2,761 patients. Systemic thrombolysis showed a significant reduction in mortality and faster hemodynamic stabilization compared to anticoagulation alone, but with an increased risk of major bleeding, particularly intracranial hemorrhage. Surgical and catheter-directed embolectomy demonstrated similar efficacy to thrombolysis, with potentially fewer bleeding complications in high-risk subgroups. Early intervention (within 2 hours of diagnosis) was consistently associated with better outcomes. Conclusion: Immediate reperfusion therapy is essential for improving survival and reducing complications in high-risk APE patients with hemodynamic instability. While thrombolysis remains the first-line treatment, embolectomy represents a safe and effective alternative when thrombolysis is contraindicated. Further randomized, multicenter trials are needed to optimize patient stratification and refine therapeutic algorithms tailored to comorbid and elderly populations.