Tobias Tichelbäcker: PRAGUE-26 Shows Catheter Lysis Beats Anticoagulation Without Ultrasound
Tobias Tichelbäcker, Specialist in Internal Medicine and Cardiology at Fachinternistische Versorgung Rodenkirchen and University Hospital Cologne, shared a post on LinkedIn:
“PRAGUE-26 – presented at European Society of Cardiology Meeting 2026 today and published in NEJM. Congratulations to Josef Kroupa, Viktor Kočka and the Charles University Prague team!
The design
- Investigator-initiated, non-industry, 11 centers, 558 pts with intermediate-high-risk PE.
- 1:1: conventional catheter-directed lysis with anticoagulation vs. anticoagulation alone.
- Lysis: 1 mg/h per catheter, approximately 20 mg alteplase over about 9 h — and no ultrasound.
The result
Primary endpoint (death, PE recurrence, cardiorespiratory decompensation or collapse 7d): 0.7% vs. 6.8% · RR 0.10 · p less than 0.001, driven mainly by fewer decompensation events
Bleeding comparable (4.6% vs. 5.0%). 2 intracranial hemorrhages, both in the lysis arm — but both explained: one during a hypertensive episode post-infusion, one with an LMWH overdose. Not a diffuse lytic signal, but a reminder that BP control and anticoagulation management matter.
PRAGUE-26 vs. HI-PEITHO
Parallels: both RCTs vs. anticoagulation, both positive, effect carried by prevented decompensation, no bleeding signal
Differences:
- Ultrasound-CDT (EkoSonic) vs. simple CDT
- Industry- vs. academically funded
- HI-PEITHO more strictly selected (approximately 87% screened, not randomized), resulting in sicker cohort; PRAGUE-26 broader (control event rate 6.8% vs. 10.3%)
- And notably: PRAGUE-26 used a slightly higher lytic dose over a longer infusion (approximately 20 mg / approximately 9 h vs. approximately 17 mg / approximately 7 h) — without ultrasound
The elephant in the room: do we even need the ultrasound? Both show catheter lysis beats anticoagulation — but neither compares US-CDT head-to-head with simple CDT. PRAGUE-26 suggests a large benefit without ultrasound: cheaper, more widely available.
Caveat: it’s a cross-trial inference, not a direct comparison.
For intermediate-high-risk PE, ‘anticoagulate and watch’ is under pressure. The next ESC guideline will be worth reading.”
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