This paper, one of many I’ve cited on this topic over the past few years, reviews the guidelines and proposes an algorithm. The main points are these:
Patients should undergo rapid risk stratification (via biomarkers and/or echocardiography).
Thrombolytics are not recommended for low risk patients without RV dysfunction.
Thrombolytics are generally recommended for patients with hypotension.
Patients who are hemodynamically stable but have RV dysfunction (as assessed via echocardiography) constitute a group who should be considered for thrombolytic therapy, but its use in this population is controversial. (The algorithm calls for thrombolytic treatment in this group, absent contraindications but the text of the article acknowledges divided opinion and the dearth of high level evidence).