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Thrombolysis for PE: Weigh Risks and Benefits

July 17, 2014

Thrombolysis for PE: Weigh Risks and Benefits

  1. Patricia Kritek, MD

In patients with intermediate-risk pulmonary embolism, thrombolytic therapy was associated with lower mortality but more bleeding.

  1. Patricia Kritek, MD

Guidelines recommend that patients with massive pulmonary embolism (PE) and hemodynamic instability be treated with thrombolysis (Circulation 2011; 123:1788). However, consensus is lacking on what to do in intermediate-risk patients (i.e., those who are hemodynamically stable but have right ventricular dysfunction). Investigators performed a meta-analysis of 16 trials conducted during the last 45 years of thrombolysis for PE. Of 2115 patients, most (71%) were classified as having intermediate-risk PE; 9.9% had low-risk PE; and 1.5% had hemodynamically unstable, high-risk PE. Risk could not be classified in the remaining patients.

At mean follow-up of 82 days, all-cause mortality was significantly lower overall in patients who received thrombolytic therapy versus anticoagulant therapy (2.2% vs. 3.9%), but major bleeding was significantly higher (9.2% vs. 3.4%), as was intracranial hemorrhage (1.5% vs. 0.2%); results were similar when only patients with intermediate-risk PE were considered. Among patients older than 65, major bleeding was significantly more common with thrombolysis than with anticoagulant therapy (13% vs. 4%). Outcomes were no different in analyses that excluded the single trial that involved catheter-directed thrombolysis.

Comment

Although a small mortality benefit is possible, consideration of thrombolysis for a hemodynamically stable patient with right ventricular dysfunction still warrants a nuanced discussion of risks versus benefits. This meta-analysis provides concrete numbers to guide that discussion. Because of elevated risk for bleeding, I would hesitate before proceeding to thrombolysis in older patients.

  • Disclosures for Patricia Kritek, MD at time of publication Speaker’s Bureau American College of Chest Physicians (Critical Care Board Review Course) Editorial boards Scientific American Medicine (Pulmonary and Critical Care Section Editor)

Citation(s):

Reader Comments (3)

Nima taheri_MD Physician, Cardiology, ccu standby phisition

I believe it has not benefits

But it should be. Consider for each patient's. Clinical

Situation
So. we. can,t put all these patients in single
Category for treatment

MD Physician, Cardiology, Mansoura University, Egypt

I think that the use of thrombolytic therapy in patients with intermediate risk acute pulmonary embolism need further studies to evaluate the risk benefit in this situation and CT guided use according the thrombus burden may help in this situation

Tahmineh Farbodara Physician, Internal Medicine, Iran

I am agree with u...Im just graguated and since being resident I watched so many cases of PE that thrombolysis saved them from death,but in intermediated risk patient it was not benefitial.
Thanks for your valuable comment.

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