The Difficult Clinical Decision of Thrombolytic Therapy for Submassive Pulmonary Embolism in a Community Hospital (original) (raw)
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Efficacy and Safety of Thrombolytic Therapy in Acute Submassive Pulmonary Embolism: Follow-Up Study
Journal of clinical medicine research, 2017
Thrombolysis in acute submassive pulmonary embolism (PE) remains controversial. So we studied impact of thrombolytic therapy in acute submassive PE in terms of mortality, hemodynamic status, improvement in right ventricular function, and safety in terms of major and minor bleeding. A single-center, prospective, randomized study of 86 patients was conducted at LPS Institute of Cardiology, G.S.V.M. Medical College, Kanpur, India. Patients received thrombolysis (single bolus of tenecteplase) with unfractionated heparin (UFH, group I) or placebo with UFH (group II). Mean age of patients was 54.35 ± 12.8 years with male dominance (M:F = 70%:30%). Smoking was the most common risk factor seen in 29% of all patients, followed by recent history of immobilization (25%), history of surgery or major trauma within past 1 month (15%), dyslipidemia (10%) and diabetes mellitus (10%). Dyspnea was the most common symptom in 80% of all patients, followed by chest pain in 55% and syncope in 6%. Primary...
Management of Massive and Submassive Pulmonary Embolism
American Journal of Therapeutics, 2013
Purpose of review Although early pulmonary revascularization is the treatment of choice for patients with high-risk (massive) pulmonary embolism, it remains controversial in patients with intermediate-risk (submassive) pulmonary embolism until recently. Recent published data on the management of high-risk and intermediate-risk pulmonary embolism patients will be the main focus of this review. Recent findings The PEITHO trial supports the rationale of risk stratification in normotensive patients with pulmonary embolism. Patients with right ventricular dilation on echocardiography and positive cardiac troponin test have a high intermediate risk of complication and death. Thrombolysis prevents hemodynamic collapse in these patients but with an increased risk of major bleeding particularly in older patients (>75 years). Reduced dose of thrombolysis and catheter-based reperfusion with or without fibrinolysis have shown promising results. Summary Thrombolysis is the treatment of choice for patients with high-risk pulmonary embolism. Surgical embolectomy is recommended in case of absolute contra-indication to thrombolysis. In patients with acute right ventricular dysfunction on cardiac imaging and myocardial injury, thrombolysis should be considered if they are 75 years or less of age and are at low risk of bleeding. Full-dose thrombolysis may be excessively risky in patients over 75 years. In patients with either RV dilation or elevated cardiac biomarker, thrombolysis is not recommended.
Determinants of in-hospital clinical outcome in patients with sub-massive pulmonary embolism
Indian Heart Journal, 2018
Introduction: There is limited data regarding in hospital determinants of clinical deterioration and outcome in sub massive pulmonary embolism (PE). We aimed to evaluate these determinants by comparing biomarkers, CT pulmonary angiogram echocardiography, electrocardiography variables. Methods: 57 patients of sub massive PE diagnosed on CT pulmonary angiogram were included. All patients received UFH on admission and were divided into two groups based on their clinical course. Group 1 comprised of patients who remained stable, group 2 of patients who showed signs of clinical deterioration. Results: There were 34(59.6%) patients in group 1 and 23(40.4%) patients in group 2. No significant difference in age, gender, BMI. 59.37% had sub massive PE, 5.26% had mortality and 40.4% had clinical deterioration. Intravenous UFH infusion given to 59.6%, systemic thrombolysis 22.8%, catheter directed mechanical breakdown 14%, surgical embolectomy in 3.5% patients. S1Q3T3, new onset RBBB, T wave inversion > 1.63 mm, Basal RV size > 40 mm, RV: LV ratio > 1.2, Global RV longitudinal strain <À10.75% and RVSP > 39 mmHg profiled high risk group. Serum BNP and CT pulmonary angiogram derived scores didn't differ significantly although CT findings helped to exclude low risk patients (specificity 88%, sensitivity 95%). Conclusions: Physicians should be aware that patients who have ECG and Echocardiography changes suggestive of right ventricular strain and dysfunction above the cut off values and have documented thrombus in Proximal branches (RPA/LPA) or in distal portion of main pulmonary artery may require aggressive management with systemic/catheter based thrombolysis besides routine anticoagulation with heparin to prevent clinical deterioration.
Erciyes Medical Journal, 2019
Introduction: Thrombolytic and anticoagulation therapy are the possible treatment modalities for submassive pulmonary embolism (PE). However, the indications are still the subject of debate. The aim of this study was to compare the efficacies of thrombolytic and standard anticoagulation treatment modalities on mortality, and also to determine the safety of thrombolytic treatment in subjects with submassive PE. Methods: Subjects with submassive PE were recruited from the intensive care unit (ICU). The demographic data, comorbidity, bedside echocardiography (ECHO) findings, treatment procedure, treatment-related side effects, total length of stay in hospital and ICU were collected. Control ECHO was performed 48 hours after the initiation of the treatment. Short-term and one year mortality were recorded. The correlation between the increased risk for major bleeding and thrombolytic treatment was assessed. Results: Fifty-four subjects with a median age of 66 (54-73) years were enrolled during the study period. 18 subjects (33.3%) underwent thrombolytic treatment and 36 subjects (66.7%) received standard anticoagulation therapy. Short-term and one year mortality were statistically lower in subjects who received thrombolytic therapy (p=.02 and p=.04, respectively). The reduction in the mean pulmonary arterial pressure was significantly higher in the thrombolytic treatment group (p<.001). Risk for major bleeding was similar between two groups. Conclusion: Thrombolytic therapy may reduce the mortality rates in subjects with submassive PE without an increase in the risk of major bleeding.
Circulation, 2013
Information about a real patient is presented in stages (boldface type) to expert clinicians (Drs Louis J. Dell'Italia and David C. McGiffin) who respond to the information, sharing his or her reasoning with the reader (regular type). A discussion by the authors follows. A 67-year-old black woman presents to the emergency department with a 1-day history of dyspnea, which began the previous morning initially with moderate exertion now progressing to dyspnea at rest. She denies chest pain, cough, palpitations, nausea, diaphoresis, lower extremity swelling, paroxysmal nocturnal dyspnea, orthopnea, presyncope, or syncope. Her medical history is notable for hypertension, diabetes mellitus, and hypothyroidism. Her medications include metoprolol tartrate 12.5 mg twice daily, metformin 1000 mg twice daily, levothyroxine 25 μg daily, and estradiol 1 mg daily for symptomatic management of hot flashes. She lives alone and is a retired schoolteacher. She does not smoke, drink alcohol, or use illicit drugs. Family history is not significant. Travel history is notable for round-trip plane flight from Alabama to Utah, arriving home 2 days previously. On physical examination her temperature is 98.4°F, pulse is 94 beats/min, blood pressure is 112/55 mm Hg in the right arm, 110/58 mm Hg in the left arm, respiratory rate 26 breaths/min, and oxygen saturation 90% on room air. She is an obese black woman (body mass index 32 kg/m 2) in mild distress secondary to shortness of breath. Jugular venous pressure is estimated at 14 cm H 2 0. Lungs are clear to auscultation. The heart rhythm is regular with a normal S1 and S2. No murmurs, rubs, or gallops are appreciated. Peripheral pulses are brisk and symmetrical with trace pretibial pitting edema. Abdominal examination is benign. Dr Louis J. Dell'Italia: This patient presents with a 24-hour history of dyspnea progressing from symptoms with exertion to now occurring at rest. Probable causes for this presenting complaint often involve serious cardiopulmonary pathology. The history and physical examination is helpful in narrowing the differential and raises particular concern for acute pulmonary thromboembolism (PE). Certain risk factors increase suspicion for venous thrombosis in this patient, including obesity, hormone replacement therapy, and recent plane flight. However, air travel less than 6 hours is associated with a very low incidence of venous thromboembolism and therefore does not represent an identifiable risk factor for thrombosis. 1 Rapid onset dyspnea at rest or exertion, as with this case, is the most common presenting symptom for acute PE. 2 Currently the patient appears hemodynamically stable, although β-blockade may blunt a tachycardic response. Coupled with the history is an examination that is remarkable for an obvious elevation of the jugular venous pressure with clear lung fields, suggestive of right heart failure. Combined with sudden dyspnea and hypoxia, these findings strongly suggest the diagnosis of acute PE. It would be prudent to evaluate for deep vein thrombosis by assessing for symptoms of calf or thigh pain and examining the lower extremities for asymmetry, tenderness, or a palpable cord. Given the broad differential diagnosis for this presentation, initial workup should include basic laboratory data, arterial blood gas, ECG, and chest x-ray. The Wells score 3 and revised Geneva score 4 may be used to calculate the clinical probability of PE (Table 1). In patients with low to intermediate clinical probability of PE, D-dimer measurement is a useful tool to determine further management. A D-dimer level below the exclusion threshold (<500 μg/L when using a quantitative ELISA assay) is highly sensitive in ruling out acute venous thromboembolism, whereas D-dimer values above the threshold warrant further evaluation. It should be noted that D-dimer testing is not indicated in patients with high clinical probability of PE, because a normal value does not reliably rule out PE in this population. The dichotomized Wells score indicates a likely probability for PE in this patient based on recent immobilization and the absence of a more probable diagnosis. Likely probability for PE warrants more definitive testing with either computed tomography (CT) pulmonary angiography or ventilationperfusion scanning. Empirical systemic anticoagulation should also be considered, particularly if more definitive diagnostic testing is not immediately available.
Research in Cardiovascular Medicine, 2016
Background: Thrombolytic therapy in patients with sub-massive pulmonary embolism (SMPTE) needs further assessment. Objectives: The current study aimed to assess a potential benefit of thrombolytic and non-thrombolytic therapy in patients with SMPTE. Patients and Methods: One hundred-nineteen patients were enrolled with SMPTE from 2006 to 2010 in the tertiary care center of Rajaie medical and research center. The patients who had pulmonary thromboemboli (PTE) and received thrombolytic plus heparin therapy and or non-thrombolytic (unfractionated heparin alone) were evaluated for hemodynamic changes (blood pressure, pulse rate, pulmonary artery systolic pressure, right ventricular failure and right ventricle enlargement), before and after 48 hours of treatment. The mortality rate was also assessed. Results: Forty-five percent of the patients with SMPTE received thrombolytic therapy (streptokinase) and 55% of SMPTE patients received non-thrombolytic therapy (unfractionated heparin). Pulse rate, pulmonary arterial pressure and tricuspid regurgitation gradient in patients receiving thrombolytic therapy reduced significantly (P = 0.001, P = 0.01 and P = 0.001, respectively). There was no significant difference before and after treatment regarding systolic blood pressure (P = 0.4), diastolic blood pressure (DBP) (P = 0.5), systolic arterial pressure (SPAP) (P = 0.1), Right ventricular (RV) function (P = 0.1) and RV size (P = 0.1). In patients who received a non-thrombolytic therapy, there were no significant differences between the groups regarding SBP (P = 0. 2), DBP (P= 0. 4) and PR (P = 0. 1), SPAP (P = 0.6), TRG (P = 0.4), RV function (P = 0.4) and RV size (P = 0.2) before and after treatment. There were no significant differences between the groups according to mortality rate. Conclusions: Thrombolytic therapy lead to earlier relief of hemodynamic condition in comparison to non-thrombolytic therapy but no changes were observed in mortality rate.
Thrombolytic therapy and outcome of patients with an acute symptomatic pulmonary embolism
Journal of Thrombosis and Haemostasis, 2012
Background: While the primary therapy for most patients with a pulmonary embolism (PE) consists of anticoagulation, the efficacy of thrombolysis relative to standard therapy remains unclear. Methods: In this retrospective cohort study of 15 944 patients with an objectively confirmed symptomatic acute PE, identified from the multicenter, international, prospective, Registro Informatizado de la Enfermedad TromboEmbo´lica (RIETE registry), we aimed to assess the association between thrombolytic therapy and all-cause mortality during the first 3 months after the diagnosis of a PE. After creating two subgroups, stratified by systolic blood pressure (SBP) (< 100 mm Hg vs. other), we used propensity scorematching for a comparison of patients who received thrombolysis to those who did not in each subgroup. Results: Patients who received thrombolysis were younger, had fewer comorbid diseases and more signs of clinical severity compared with those who did not receive it. In the subgroup with systolic hypotension, analysis of propensity score-matched pairs (n = 94 pairs) showed a non-statistically significant but clinically relevant lower risk of death for thrombolysis compared with no thrombolysis (odds ratio [OR] 0.72; 95% confidence interval [CI], 0.36-1.46; P = 0.37). In the normotensive subgroup, analysis of propensity score-matched pairs (n = 217 pairs) showed a statistically significant and clinically meaningful increased risk of death for thrombolysis compared with no thrombolysis (OR 2.32; 95% CI, 1.15-4.68; P = 0.018). When we imputed data for missing values for echocardiography and troponin tests in the group of normotensive patients, we no longer detected the increased risk of death associated with thrombolytic therapy. Conclusions: In normotensive patients with acute symptomatic PE, thrombolytic therapy is associated with a higher risk of death than no thrombolytic therapy. In hemodynamically unstable patients, thrombolytic therapy is possibly associated with a lower risk of death than no thrombolytic therapy. However, study design limitations do not imply a causal relationship between thrombolytics and outcome.
Erciyes Medical Journal, 2019
Objective: Thrombolytic and anticoagulation therapy modalities are the possible treatment for submassive pulmonary em-bolism (PE). However, the indications are still the subject of debate. The aim of the present study was to compare the effi-cacies of thrombolytic and standard anticoagulation treatment modalities on mortality and also to determine the safety of thrombolytic treatment in subjects with submassive PE. Materials and Methods: Subjects with submassive PE were recruited from the intensive care unit (ICU). Demographic data, comorbidity, bedside echocardiography (ECHO) findings, treatment procedure, treatment-related side effects, and total length of stay in the hospital and ICU were collected. Control ECHO was performed 48 h after the initiation of treatment. Short-term and 1-year mortality rates were recorded. The correlation between the increased risk for major bleeding and thrombolytic treatment was assessed. Results: A total of 54 subjects were enrolled during the study period. The median age of the subjects was 66 (54-73) years. Of the 54 subjects, 18 (33.3%) underwent thrombolytic treatment, and 36 (66.7%) received standard anticoagulation therapy. Short-term and 1-year mortality rates were statistically lower in subjects who received thrombolytic therapy (p=0.02 and p=0.04, respectively). The reduction in mean pulmonary arterial pressure was significantly higher in the thrombolytic treatment group (p<0.001). Risk for major bleeding was similar between the two. Conclusion: Thrombolytic therapy may reduce the mortality rates in subjects with submassive PE without an increase in the risk of major bleeding.
Vascular and Endovascular Surgery, 2019
A retrospective review from July 2016 to April 2018 was performed of 23 patients with submassive pulmonary embolism (PE) who received catheter-directed thrombolysis (CDT). Five (22%) of the 23 patients were discharged the same day from the intensive care unit (ICU) following thrombolysis completion. Their presentation, hospital courses, complications, and follow-up are reviewed. All 5 patients were diagnosed using chest computed tomography (CT) demonstrating a clot in the pulmonary vasculature and right ventricle dysfunction based on abnormal right ventricle to left ventricle (RV/LV) ratio. Patients with severe right heart dysfunction (RV/LV ratio ≥1.4) were protocolized to receive CDT via EkoSonic catheters (EKOS Corporation). Postoperatively, patients were admitted to the ICU with continuous alteplase at 1 mg/h. Echocardiography was then performed after 24 hours of therapy to assess right ventricle function and removal of EkoSonic catheters. Patients with reversal of right heart d...