Treating Large Pulmonary Emboli
Treating Large Pulmonary Emboli
Thrombolysis is advocated for massive pulmonary emboli. Randomized trials have shown that thrombolysis results in superior short-term hemodynamic and angiographic effects when compared with anticoagulation. However by 7 days, pulmonary artery blood flow is similar in patients treated with either modality. The one prospective randomized trial to examine the clinical efficacy of thrombolysis compared with intravenous heparin for patients with massive pulmonary emboli was a small study comparing eight patients who did or did not receive streptokinase. Patients who received thrombolysis survived and did not develop pulmonary hypertension at 2 years, whereas all patients who received anticoagulation alone died within several hours of presentation. An analysis of a nationwide sample in the United States between 1999 and 2008 demonstrated an all-cause and pulmonary emboli-attributable mortality benefit for thrombolysis in unstable patients with pulmonary emboli. A meta-analysis of 11 randomized studies that compared heparin to heparin with thrombolysis for patients with pulmonary emboli showed a trend toward reduction in mortality and recurrent pulmonary emboli in patients with hemodynamic instability. A similar analysis published as part of the AHA guidelines for the treatment of submassive and massive pulmonary emboli combined the results of four registries and came to similar conclusions . It is noteworthy that an analysis of outcomes of 108 patients with massive pulmonary emboli in ICOPER failed to show benefit for thrombolysis regarding pulmonary emboli recurrence or mortality.
Data Regarding Systemic Thrombolysis for Massive Pulmonary Emboli
Thrombolysis is advocated for massive pulmonary emboli. Randomized trials have shown that thrombolysis results in superior short-term hemodynamic and angiographic effects when compared with anticoagulation. However by 7 days, pulmonary artery blood flow is similar in patients treated with either modality. The one prospective randomized trial to examine the clinical efficacy of thrombolysis compared with intravenous heparin for patients with massive pulmonary emboli was a small study comparing eight patients who did or did not receive streptokinase. Patients who received thrombolysis survived and did not develop pulmonary hypertension at 2 years, whereas all patients who received anticoagulation alone died within several hours of presentation. An analysis of a nationwide sample in the United States between 1999 and 2008 demonstrated an all-cause and pulmonary emboli-attributable mortality benefit for thrombolysis in unstable patients with pulmonary emboli. A meta-analysis of 11 randomized studies that compared heparin to heparin with thrombolysis for patients with pulmonary emboli showed a trend toward reduction in mortality and recurrent pulmonary emboli in patients with hemodynamic instability. A similar analysis published as part of the AHA guidelines for the treatment of submassive and massive pulmonary emboli combined the results of four registries and came to similar conclusions . It is noteworthy that an analysis of outcomes of 108 patients with massive pulmonary emboli in ICOPER failed to show benefit for thrombolysis regarding pulmonary emboli recurrence or mortality.