Pereverzeva KG, Yakushin SS, Peregudova NN. Anticoagulants vs thrombolytic therapy for the management of right heart thrombus in pulmonary embolism: A systematic review. World J Cardiol 2026; 18(6): 120186 [DOI: 10.4330/wjc.120186]
Corresponding Author of This Article
Sergey S Yakushin, Department of Hospital Therapy with a Course in Medical and Social Expertise, Federal State Budgetary Educational Institution of Higher Education I.P. Pavlov Ryazan State Medical University of the Ministry of Health of the Russian Federation, 96 Stroykova Street, Ryazan 390026, Russia. s.yakushin@rzgmu.ru
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Cardiac & Cardiovascular Systems
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Pereverzeva KG, Yakushin SS, Peregudova NN. Anticoagulants vs thrombolytic therapy for the management of right heart thrombus in pulmonary embolism: A systematic review. World J Cardiol 2026; 18(6): 120186 [DOI: 10.4330/wjc.120186]
World J Cardiol. Jun 26, 2026; 18(6): 120186 Published online Jun 26, 2026. doi: 10.4330/wjc.120186
Anticoagulants vs thrombolytic therapy for the management of right heart thrombus in pulmonary embolism: A systematic review
Kristina G Pereverzeva, Sergey S Yakushin, Natalia N Peregudova
Kristina G Pereverzeva, Sergey S Yakushin, Natalia N Peregudova, Department of Hospital Therapy with a Course in Medical and Social Expertise, Federal State Budgetary Educational Institution of Higher Education I.P. Pavlov Ryazan State Medical University of the Ministry of Health of the Russian Federation, Ryazan 390026, Russia
Author contributions: Pereverzeva KG performed the study conceptualization, methodology, data curation, drafting of the manuscript and editing of the subsequent versions, and supervision of the project; Peregudova NN performed the literature review data curation, drafting of the manuscript and editing of the subsequent versions; Yakushin SS performed the study conceptualization, provided critical resources, contributed to the reviewing and editing of the various manuscript versions, and performed project administration.
Conflict-of-interest statement: There are no conflicts of interest associated with the senior author or other coauthors who contributed their efforts in this manuscript.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.
Corresponding author: Sergey S Yakushin, Department of Hospital Therapy with a Course in Medical and Social Expertise, Federal State Budgetary Educational Institution of Higher Education I.P. Pavlov Ryazan State Medical University of the Ministry of Health of the Russian Federation, 96 Stroykova Street, Ryazan 390026, Russia. s.yakushin@rzgmu.ru
Received: February 28, 2026 Revised: April 21, 2026 Accepted: May 6, 2026 Published online: June 26, 2026 Processing time: 120 Days and 20.2 Hours
Abstract
BACKGROUND
Right heart thrombi (RHT) are associated with high mortality in patients with pulmonary embolism (PE). Thrombolytic therapy (TLT) and anticoagulation therapy (ACT) are the main treatment options. However, the optimal treatment strategy remains controversial due to a lack of randomized controlled trials.
AIM
To compare the efficacy and safety of TLT vs isolated ACT in patients with RHT and PE.
METHODS
We searched PubMed, Scopus, and Wiley Online Library from database inception to January 20, 2026, using a comprehensive strategy combining terms for RHT (including “right heart thrombus”, “right ventricular thrombus”, “atrial thrombus”, “thrombus in transit”), PE (“pulmonary embolism” OR “PE”), and thrombolysis (“thrombolysis”, “fibrinolysis”, “alteplase”, “tenecteplase”, and “streptokinase”). Inclusion criteria involved the following: Adults with confirmed RHT in acute PE; direct comparison of TLT + ACT vs ACT alone; intention-to-treat design; and case series with n > 5 per group.
RESULTS
Five observational studies (n = 205 patients) were included. TLT did not significantly reduce early all-cause mortality during hospitalization (OR = 0.36, 95%CI: 0.10-1.29, and P = 0.12). The heterogeneity of the results across the included studies was low and not statistically significant (I2 = 18% and P = 0.30). TLT also did not significantly reduce all-cause mortality at 30 days (OR = 0.26, 95%CI: 0.04-1.64, and P = 0.15). The heterogeneity of the results across the included studies was moderate and not statistically significant (I2 = 51% and P = 0.13). No subgroup analyses by hemodynamic status or thrombus type were possible.
CONCLUSION
Routine thrombolysis does not significantly reduce mortality compared with ACT alone in the overall cohort of RHT and PE patients.
Core Tip: Management of patients with right heart thrombi in pulmonary embolism (PE) remains challenging. This meta-analysis of 205 patients did not reveal a significant advantage of routine thrombolytic therapy over isolated anticoagulation in reducing mortality. Our data do not support universal use of either strategy. Treatment decisions should be individualized, and clinicians should follow current guidelines, which recommend thrombolysis for hemodynamically unstable patients with massive PE.
