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Ben Creagh-Brown: PRAGUE-26 and HI-PEITHO Similar Benefits With Important Differences
Ben Creagh-Brown/ LinkedIn
Sep 4, 2026, 21:50

Ben Creagh-Brown: PRAGUE-26 and HI-PEITHO Similar Benefits With Important Differences

Ben Creagh-Brown, Consultant Physician at Royal Surrey County Hospital NHS Foundation Trust, shared a post on LinkedIn about a recent article by J. Kroupa et al. published in NEJM, adding:

“Another important PE trial (PRAGUE-26) has just been published by the NEJM Group. Congratulations to Viktor Kocka and team.

  • P: 558 hemodynamically stable adults with acute, intermediate-high-risk PE — proximal PE on CTA, simplified PESI score of 1 or higher, RV dysfunction plus elevated troponin or natriuretic peptide.
  • I: Conventional catheter-directed thrombolysis (standard 4-French catheter, no ultrasound) with alteplase (1mg bolus plus 1mg/hr/catheter, up to 20mg bilateral or 10mg unilateral) and anticoagulation.
  • C: Anticoagulation alone.
  • O: Efficacy: CDT cut the 7-day composite risk of death, PE recurrence, or cardiorespiratory decompensation by 90% (0.7% vs. 6.8%, RR 0.10, P<0.001).

Safety: No difference in clinically relevant bleeding by day 7 (4.6% vs. 5.0%) or major bleeding (1.4% vs. 2.2%); ICH in 2 patients (0.7%) with thrombolysis vs. none with standard care.

Similarities to HI-PEITHO: Both tested catheter-delivered fibrinolysis (with or without ultrasound) vs. anticoagulation alone, with near-identical composite endpoints including a NEWS score of 9 or higher trigger.

Both showed a similar absolute risk reduction (approximately 6 points, NNT of approximately 16) despite very different relative risks (0.39 vs 0.10), driven almost entirely by decompensation, not death. Neither reached significance on ICH, and neither was powered to.

Differences: PRAGUE-26 skipped HI-PEITHO’s extra distress-vital enrolment criteria and used a modestly higher, longer alteplase infusion. Its adjudication committee was unblinded; HI-PEITHO’s wasn’t. HI-PEITHO was industry-sponsored with one proprietary device; PRAGUE-26 was investigator-initiated with a standard catheter.

Both excluded the patients I most often see needing this: active cancer, recent major surgery. Neither reports how many screened patients that removed — HI-PEITHO buries 3,295 screen-failures in one figure; PRAGUE-26 admits it didn’t keep screening logs. CONSORT calls for exclusions itemised by reason. Without that, we can’t judge how far this generalises to real practice.

Take-homes: I think there’s a real benefit to CDT in the right population, delivered fast, and a large unmet need. I don’t think US-facilitation is doing much. I’m less worried than others about NEWS2 as a surrogate or its bias potential.

What’s next?

An international trial with fewer exclusions, powered on outcomes that matter to patients, could actually change practice. UK centre available if anyone’s building one.”

Title: Catheter-Directed Thrombolysis in Intermediate-High–Risk Pulmonary Embolism

Authors: J. Kroupa, M. Radvan, J. Mrozek, M. Sluka, S. Jirous, O. Hlinomaz, M. Pliva, J. Pudil, H. Voberkova, K. Bartoskova, M. Poloczek, M. Kamenik, M. Brabec, E. Lichnerova, M. Hutyra, I. Bernat, M. Novak, J. Horakova, L. Jelinkova, T. Knize, P. Tousek, C. Stechovsky, F. Varhanik, Z. Coufal, J. Jarkovsky, V. Kocka

Ben Creagh-Brown

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Alteplase Anticoagulation Ben Creagh-Brown Blood C. Stechovsky Cardiology Catheter Directed Thrombolysis CTA E. Lichnerova F. Varhanik H. Voberkova Health Hematology Hemostasis Hemostasis News Hemostasis Today HI-PEITHO I. Bernat J. Horakova J. Jarkovsky J. Kroupa J. Mrozek J. Pudil K. Bartoskova L. Jelinkova M. Brabec M. Hutyra M. Kamenik M. Novak M. Pliva M. Poloczek M. Radvan M. Sluka Medicine natriuretic peptide NEJM NEJM Group O. Hlinomaz P. Tousek PE PRAGUE-26 S. Jirous T. Knize troponin V. Kocka Viktor Kočka Z. Coufal
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