An overview of thrombolytic therapy for pulmonary embolism: a single centre experience

Pulmonary embolism (PE) is considered to be a major cause of mortality, morbidity and hospitalization in Europe. Haemody-namic benefits of thrombolysis in patients with shock and hypotension are undeni-able, but the role of thrombolytic therapy on the outcome of haemodynamically sta-ble patients still remains controversial. This is a retrospective analysis of patients with acute PE treated with thrombolytic therapy in medical intensive care unit (ICU), University Hospital Sveti Duh, be-tween March 2014 and April 2015 . Twenty two of 75 (29%) patients with PE received thrombolytic therapy. The mean age of patients was 63 years, 45% were male and 55% female. The major symp-toms were: dyspnea (73%), chest pain (18%) and syncope (9%). 27% of patients receiving thrombolytic therapy were haemodynamically unstable and 73% were stable. All patients had an extensive clot burden on computed tomographic pul-monary angiography (CTPA). All haemo-dynamically stable patients had echocar-diographic signs of right ventricular (RV) dysfunction. Troponin I was positive in all haemodynamically unstable patients and in 50% of haemodynamically stable pa-tients. Only one (5%) haemodynamically unstable patient died but not because of PE or therapy complication. All other patients survived and recovered completely. Two patients (9%) had major non-intracranial bleeding complications, which were suc-cessfully treated with supportive therapy.

pulmonary embolism, thrombo-lytic therapy, right ventricular dysfunction, bleeding

1. Heit JA. The epidemiology of venous thromboembolism in the community. Arterioscler Thromb Vasc Biol 2008;28(3):370–372.

2. Cohen AT, Agnelli G, Anderson FA, Arcelus JI, Bergqvist D, Brecht JG, Greer IA, Heit JA, Hutchinson JL, Kakkar AK, Mottier D, Oger E, Samama MM, Spannagl M. Venous thromboembolism (VTE) in Europe. The number of VTE events and associated mor-bidity and mortality. Thromb Haemost 2007;98(4):756–764.

3. Heit JA III, Silverstein MD, Mohr DN, Petterson TM, O’Fallon WM, Melton LJ III. Risk factors for deep vein thrombosis and pul-monary embolism: a population based case-control study. Arch Intern Med 2000;160(6):809–815.

4. Pollack CV, Schreiber D, Goldhaber SZ, Slattery D, Fanikos J, O’Neil BJ, Thompson JR, Hiestand B, Briese BA, Pendleton RC, Miller CD, Kline JA. Clinical characteristics, management, and outcomes of patients diagnosed with acute pulmonary embolism in the emergency department: initial report of EMPEROR(Multicenter Emergency Medicine PulmonaryEmbolism in the RealWorld Registry). J Am Coll Cardiol 2011;57(6):700–706. European Heart Journal (2014) 35, 3033–3080.

5. Konstantinides SV , Torbicki A, Agnelli G, Danchin N, Fitzmaurice D, Galiè N, Gibbs JS, Huisman MV, Humbert M, Kucher N, Lang I, Lankeit M, Lekakis J, Maack C, Mayer E, Meneveau N, Perrier A, Pruszczyk P, Rasmussen LH, Schindler TH, Svitil P, Vonk Noordegraaf A, Zamorano JL, Zompatori M. 2014 ESC Guidelines on the diagnosis and management of acute pulmonary embo-lism. Eur Heart J. 2014 Nov 14;35(43):3033-69.

6. Goldhaber SZ, Haire WD, Feldstein ML, Miller M, Toltzis R, Smith JL, Taveira da Silva AM,ComePC, Lee RT, Parker JA. Alteplase versus heparin in acute pulmonary embolism: randomised trial assessing right-ventricular function and pulmonary perfusion. Lancet 1993;341(8844):507–511.

7. Daniels LB, Parker JA, Patel SR, Grodstein F, Goldhaber SZ. Relation of duration of symptoms with response to thrombolytic therapy in pulmonary embolism. Am J Cardiol 1997;80(2):184–188.

8. Goldhaber SZ. Thrombolysis in pulmonary embolism: a debatable indication. Thromb Haemost 2001;86:444-451.

9. Goldhaber SZ. Thrombolysis in pulmonary embolism: a large-scale clinical trial is overdue. Circulation 2001;104:2876-2878.

10. Konstantinides S, Geibel A, Heusel G, Heinrich F, Kasper W. Heparin plus alteplase compared with heparin alone in patients with submassive pulmonary embolism. N Engl J Med. 2002 Oct 10;347(15):1143-50.

11. Kanter DS, Mikkola KM, Patel SR, Parker JA, Goldhaber SZ. Thrombolytic therapy for pulmonary embolism. Frequency of intrac-ranial hemorrhage and associated risk factors. Chest 1997;111(5):1241–1245.

12. Wan S, Quinlan DJ, Agnelli G, EikelboomJW. Thrombolysiscompared with heparin for the initial treatment of pulmonary embo-lism: a meta-analysis of the randomized controlled trials. Circulation 2004;110(6):744–749.

13. Stein PD, Matta F. Thrombolytic therapy in unstable patients with acute pulmonary embolism: saves lives but underused. Am J Med 2012;125(5):465–470.

14. Meyer G, Vicaut E, DanaysT, Agnelli G, Becattini C, Beyer-Westendorf J, Bluhmki E, Bouvaist H, Brenner B, Couturaud F, Dellas C, Empen K, Franca A, Galie` N, Geibel A, Goldhaber SZ, Jimenez D, Kozak M, Kupatt C, Kucher N, Lang IM, Lankeit M, Men-eveau N, Pacouret G, Palazzini M, Petris A, Pruszczyk P, Rugolotto M, Salvi A, Schellong S, Sebbane M, Sobkowicz B, Stefanovic BS, Thiele H, Torbicki A, Verschuren F, Konstantinides SV. Fibrinolysis for patients with intermediate-risk pulmonary embolism. N Engl J Med 2014;370(15):1402–1411.

15. Kline JA, Nordenholz KE, Courtney DM, Kabrhel C, Jones AE, Rondina MT, Diercks DB, Klinger JR, Hernandez J. Treatment of submassive pulmonary embolism with tenecteplase or placebo: cardiopulmonary outcomes at three months (TOPCOAT): Multi-center double-blind, placebo-controlled randomized trial. J Thromb Haemost 2014.

16. Levine MN, Goldhaber SZ, Gore JM, Hirsh J, Califf RM. Hemorrhagic complications of thrombolytic therapy in the treatment of myocardial infarction and venous thromboembolism. Chest 1995;108(4 Suppl):291S–301S.

17. Mikkola KM, Patel SR, Parker JA, Grodstein F, Goldhaber SZ. Increasing age is a major risk factor for hemorrhagic complications after pulmonary embolism thrombolysis. Am Heart J 1997;134(1):69–72.