• Clinically relevant reduction of RVD; Clinical deterioration requiring escalation of treatment [ Time Frame: 7 days from Tenecteplase or Placebo ] [ Designated as safety issue: No ]
• PE recurrence [ Time Frame: 30 days ] [ Designated as safety issue: No ]
• Death [ Time Frame: 30 days ] [ Designated as safety issue: Yes ]

• • Clinically relevant reduction of RVD at 7 days from Tenecteplase or Placebo injection,
• • Clinical deterioration within 7 days from Tenecteplase or Placebo injection requiring escalation of treatment, defined as:
• o Secondary thrombolysis for one of the following indications:
• a) deteriorating clinical symptoms, particularly dyspnea, or worsening respiratory failure due to pulmonary embolism;
• b) persistent or worsening pulmonary hypertension or right ventricular dysfunction on echocardiography or right heart catheterization;
• o Endotracheal intubation,
• o Cardiopulmonary resuscitation,
• o Emergency surgical embolectomy or catheter thrombus fragmentation.
• • Haemodynamic collapse within 7 days from Tenecteplase or Placebo injection defined as systolic blood pressure <90mmHg or a drop >40mmHg for at least 30 minutes (or the need for supportive measures to maintain systolic blood pressure >90mmHg) with sign
• • PE recurrence at 30 days
• • Death at 30 days

To assess the efficacy and safety of Tenecteplase versus Placebo in normotensive patients with sub-massive Pulmonary Embolism and Right Ventricular Dysfunction (RVD) all receiving unfractionated heparin (UFH)

In patients with major acute PE thrombolysis has been shown to be life saving (22). Recent registries showed the beneficial effect of thrombolysis also in patients with PE not associated with shock or hypotension (4-23). In these patients thrombolytic treatment has been shown to obtain an improvement of 37% in lung perfusion, detected by lung scan, with respect to an improvement of 18.8% obtained by heparin treatment (24). In a different trial, rt-PA resulted in a faster and greater improvement of pulmonary artery hypertension than heparin treatment (25). Indeed, PE has a wide spectrum of severity at presentation and it is conceivable that the use of more aggressive treatments should be reserved to patients at high risk for adverse outcome. Hence, the search started of prognostic factors of adverse outcome in patients with pulmonary embolism.

RVD has been associated with early adverse outcome (PE recurrence and mortality) in patients with acute PE (26-28; 3). In-hospital mortality in PE patients with and without echocardiographic RVD has been found to be 18.4% and 5.7%, respectively (3). Ribeiro et al. found a higher mortality in patients with PE and severe RVD: in-hospital mortality was 7.9% in the overall population with respect to 14.3% in patients with severe RVD (5). The ICOPER registry reported a 2-week mortality of 15.9% in patients presenting with RVD in comparison with 8% in patients without RVD (23). In MAPPET 10% of patients with RVD died within 30 days as compared to 4.1% of patients without (4).

RVD is a common finding in patients with acute PE and normal blood pressure (BP) (29-33). Recent data suggest that patients with objectively confirmed PE, normal BP and echocardiographic evidence of RVD have a high incidence of adverse outcome (7) and may potentially benefit from more aggressive treatment (34-35). In a recent study patients with acute PE were classified according to the presence of RVD and hypotension; the short-term mortality and the incidence of PE-related shock in patients with normal BP and echo RVD was respectively 5% and 10%. None of the patients with normal BP and no RVD died or experienced PE-related shock (6).

It has been recently demonstrated in patients with PE and pulmonary hypertension or RVD but without arterial hypotension or shock, that rt-PA significantly reduces the incidence of adverse in-hospital outcome events (death and clinical deterioration) with respect to heparin (8).

Consecutive patients with symptomatic PE, since no more than four days, confirmed by objective testing (high probability lung scan or intermediate probability lung scan and objectively confirmed deep vein thrombosis or spiral CT or pulmonary angiography or TE echocardiography) will undergo echocardiographic examination within 24 hour from diagnosis. Patients with RVD and normal BP (Systolic BP> 100 mmHg) will be included in the study.

180 patients will be randomized in the study. The patients included in the study will be randomized, in a double blind fashion, to receive Tenecteplase + UFH (90 patients) or Placebo + UFH (90 patients).

Study treatment should be administered within 6 hours from echocardiography. Echocardiography will be repeated at 24 hours and 7 days or discharge (whichever comes first) from Tenecteplase or Placebo injection. A Follow-up visit at 30 days from randomization will include: clinical history, physical examination and ECG and an echocardiographic examination.

Inclusion Criteria:

• age between 18 and 85;
• symptomatic PE confirmed by: high probability lung scan, or intermediate probability lung scan and objectively confirmed deep vein thrombosis, or spiral CT-scan or pulmonary angiography or TE echocardiography;
• normal blood pressure (SBP >100mmHg);
• RVD at echocardiography (see criteria);
• written informed consent.

Exclusion Criteria:

• absence of RVD at echocardiography;
• shock or hypotension (SBP < 100 mmHg);
• therapeutic heparin (UFH or LMWH) treatment for more than 48 hours prior to randomization;
• administration of thrombolytic agents within the previous 4 days;
• vena cava filter insertion or pulmonary thrombectomy within the previous 4 days
• chronic pulmonary hypertension or severe COPD;
• hypertension defined as blood pressure >180/110 mm Hg (systolic BP >180 mm Hg and/or diastolic BP >110 mm Hg) on a single, reliable measurement during current admission at enrolling site prior to randomisation;
• use of GP IIb/IIIa antagonists within the preceding 7 days;
• significant bleeding disorders either at present or within the past 6 months;
• active peptic ulceration;
• known diabetic haemorrhagic retinopathy or other haemorrhagic ophthalmic conditions;
• known haemorrhagic diathesis;
• known arterial aneurysm and known arterial/venous malformation;
• known neoplasm with increased bleeding risk;
• prolonged cardiopulmonary resuscitation (>10 minutes) in the previous two weeks;
• current oral anticoagulation;
• major surgery, biopsy of a parenchymal organ, or significant trauma within the past 2 months;
• any known history of stroke or transient ischaemic attack (TIA) or dementia;
• any recent head trauma and any other trauma occurring after onset of the current pulmonary embolism;
• any known history of central nervous system damage (i.e. neoplasm, aneurysm, intracranial or spinal surgery);
• known subacute bacterial endocarditis;
• known acute pancreatitis;
• known severe hepatic dysfunction, including hepatic failure, cirrhosis, portal hypertension
• (oesophageal varices) and active hepatitis;
• pregnancy or lactation or parturition within the previous 30 days;
• women of childbearing potential must have a negative pregnancy test, or use a medically accepted method of birth control;
• treatment with an investigational drug under another study protocol in the past 7 days;
• previous enrolment in this study;
• known hypersensitivity to Tenecteplase, Alteplase, unfractionated heparin, or to any of the excipients;
• anticipated or obvious problem with vascular access;
• any other condition that the investigator feels would place the patient at increased risk if the investigational therapy is initiated;
• inability to follow protocol requirements