Elsevier

Critical Care Clinics

Volume 27, Issue 4, October 2011, Pages 953-967
Critical Care Clinics

Mortality Risk Assessment and the Role of Thrombolysis in Pulmonary Embolism

https://doi.org/10.1016/j.ccc.2011.09.008Get rights and content

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Defining High-Risk PE

Acute PE is not universally life threatening, but rather covers a wide spectrum of clinical severity and death risk. In various studies, early (30-day or in-hospital) mortality rates were reported to range between less than 1% and well over 50%, mostly depending on the baseline clinical profile of the patients studied.4, 5, 6, 7, 8, 9, 14

It is now well established that the principal pathophysiological factor that determines disease severity and consequently the patients’ clinical course and

Risk-Adjusted Diagnostic Approach to PE

Numerous multistep algorithms have been proposed and prospectively validated for the diagnostic workup of normotensive patients with suspected PE. Recent algorithms are based on the superior diagnostic sensitivity and specificity of multidetector-row computed tomography (MDCT)/pulmonary angiography, and its ability to confirm and in particular safely exclude PE without the need for venous ultrasound as an intermediate step.25, 29, 30, 31 On the other hand, management of the hemodynamically

Benefits of Thrombolysis in Acute PE

In view of the high early mortality and complication risk associated with high-risk PE,5, 26, 27 existing guidelines25, 35 and the overwhelming majority of experts and clinicians agree that patients who present with persistent arterial hypotension or shock are in need of immediate pharmacologic or mechanical recanalization of the occluded pulmonary arteries.

In early reports dating back to 1971, streptokinase infusion over 72 hours resulted in a significant reduction of systolic pulmonary artery

Potential Risks of Thrombolysis

Pooled data from controlled thrombolysis trials in PE, which either compared thrombolysis with heparin alone or different thrombolytic regimens with each other,37, 41, 43, 47, 48, 49, 50, 51, 52, 53, 54 revealed a 13% cumulative rate of major bleeding and a 1.8% rate of intracranial/fatal hemorrhage.55 Major hemorrhage has been less common in the most recent (and largest) trials,44, 47 in agreement with the notion that thrombolysis-related bleeding rates may be lower when noninvasive imaging

Current Use of Thrombolysis in Acute PE with High Risk for Early Death

Although the angiographic and hemodynamic benefits of thrombolysis are unequivocal, at least over the short term, the (presumed) favorable effects of thrombolysis on the clinical outcome of patients with PE have thus far not been convincingly demonstrated. As already mentioned, this partly relies on the fact that the majority of thrombolysis trials in PE were too small to address clinical end points. Even the most recent and largest of these trials failed to show a survival benefit,44, 47

Potential Role of Thrombolysis in Intermediate-Risk (Submassive) PE

At present, low molecular weight heparin or fondaparinux is considered adequate treatment for most normotensive patients with pulmonary embolism, whereas routine thrombolysis is generally not recommended as a first-line therapeutic option.25, 35 However, the results of the most recent randomized thrombolysis trial47 can be interpreted as indicating that early thrombolysis may be considered in selected patients with “nonmassive,” non-high-risk PE including, for example, those with comorbidities

Thrombolysis in Current and Emerging Concepts of PE Management

Experts and recently updated guidelines agree that thrombolysis is indicated patients with acute PE who are at high risk for early death, that is, in patients presenting with arterial hypotension and shock or refractory hypoxemia. On the other hand, heparin (unfractionated or low molecular weight) or fondaparinux is adequate treatment for most normotensive patients with PE (see Fig. 1). Recombinant tissue plasminogen activator (alteplase), given as a 100-mg infusion over 2 hours, is considered

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    A version of this article originally appeared in Clinics in Chest Medicine, 31:4.

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