HWN Suggests

The Critical Pulmonary Embolism Patient

Massive PE: Thrombolytics are supported by several international organizations as first line therapy (ACCP, AHA, EHA, & ACEP... rt-PA 50mg over 2 hours has shown similar efficacy to 100mg over 2 hours in clinical outcomes with a better safety profile (less bleeding).

Submassive PE: Thrombolytic therapy controversial and confusing. The reason for the controversy is mortality benefits have been mixed amongst studies while there is a real 2 – 3% ICH rate with thrombolysis. Also, there have been no head-to-head comparisons of thrombolytic agents conducted, to help select one over another. International organizations can’t even agree on recommendations:

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 What’s the Code Dose of tPA?

Suppose you have a patient in whom you highly suspect a pulmonary embolism (PE) that devolves into PEA arrest while awaiting a CT angiogram. Or, what about a patient with an ECG showing clear STEMI that loses pulses? The dose of tPA in cardiac arrest is somewhere between 50-100 mg given as a bolus +/- infusion.

Articles of Interest

Clinical controversies in thrombolytic therapy for the management of acute pulmonary embolism

Despite published guidelines and review articles, select aspects of thrombolytic therapy for the management of pulmonary embolism remain controversial; therefore, clinical practice varies from institution to institution and from practitioner to practitioner.

Mixed Results for Thrombolysis in Pulmonary Embolism

The role of thrombolytic therapy for the treatment of pulmonary embolism has been unclear, as it has been difficult to measure the precise balance between enhanced clot-dissolving efficacy and greater bleeding risk produced by thrombolysis when compared with conventional anticoagulation.

Submassive & Massive PE

Don't delay thrombolysis if this is an option. Thrombolysis is the only intervention which is evidence-supported to improve mortality in these cases. All other interventions (pressor, inhaled vasodilators, etc) are merely intended to stabilize the patient until thrombolysis can be performed.

Submassive PE 2017: Getting ’em off the cliff

If our goal from thrombolysis is merely to avoid PEA arrest, all we need to do is reduce the pulmonary pressures somewhat (not normalize them). This may be achievable with lower doses of alteplase than have been used historically, with a superior safety profile.

The Argument for Systemic Thrombolytics in Submassive Pulmonary Embolism

Pulmonary embolism clearly exists on a spectrum from the urgent end being the sub-segmental clots with mild symptoms to the peri-arrest (or arrested) massive PE. In between there are thousands of shades of severity. We define submassive PE as any embolism with right ventricular strain.

Thrombolysis for PE

There is insufficient evidence to support thrombolysis in addition to heparin for unselected PE patients. However, hemodynamically unstable PE patients have a significant benefit with thrombolysis with a NNT = 10 to prevent recurrent PE or death at 30-days.

Thrombolysis for submassive pulmonary embolus

The use of thrombolytics for the treatment of submassive PE is controversial — the limited documented benefit (e.g. improved hemodynamics, potential for less chronic pulmonary hypertension) must be weighed against the increased risk of life-threatening hemorrhage and the availability of other therapies (e.g. catheter-directed thrombolysis or clot retrieval)

Thrombolytic therapy for pulmonary embolism

Low‐quality evidence suggests that thrombolytics reduce death following acute pulmonary embolism compared with heparin. The included studies used a variety of thrombolytic drugs.

Thrombolytics for Submassive Pulmonary Embolism

The use of thrombolytic therapy in hemodynamically stable patients with signs of right ventricular (RV) dysfunction – i.e. “submassive” PE – is highly debated. The guidelines vary widely in the their recommendations, from firmly stating “Do not offer pharmacological systemic thrombolytic therapy to patients with PE and haemodynamic stability” (NICE), to noting that there is insufficient evidence to make recommendations (ACEP), to clearly recommending thrombolysis when there is evidence of RV dysfunction or elevated cardiac biomarkers (AHA).

Treatment of Submassive Pulmonary Embolism (PE): Full Dose, Half Dose, or No Dose?

Submassive pulmonary embolism (PE) is responsible for approximately 20% of all PEs. Although the in-hospital mortality has been reported as about 5%, there is significant morbidity associated with this diagnosis such as chronic pulmonary hypertension, impaired quality of life, persistent right ventricular disfunction, and recurrent venous thromboembolism.

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the NNT

May reduce death and recurrent PE; increased risk of major and minor hemorrhagic events... PE can be categorized as low-risk, submassive (associated with evidence of right heart strain), or massive (associated with hemodynamic instability). The latter two subtypes are associated with increased morbidity and mortality. Traditionally, anticoagulation has been the mainstay of treatment. In massive PE, however, it is important to restore pulmonary blood flow rapidly, which is often accomplished by the use of thrombolytic agents or surgical embolectomy.