scholarly journals Systemic Thrombolytic Therapy for Massive and Submassive Pulmonary Embolism

2018 ◽  
Vol 33 (1) ◽  
pp. 74-89 ◽  
Author(s):  
Lauren A. Igneri ◽  
John M. Hammer
Keyword(s):  
Pulmonary Embolism ◽  
Thrombolytic Therapy ◽  
English Language ◽  
Right Ventricular Dysfunction ◽  
Hemodynamic Instability ◽  
Minor Bleeding ◽  
Increased Risk ◽  
Submassive Pulmonary Embolism ◽  
Systemic Thrombolytic Therapy

Objective: To critically evaluate the published literature assessing the safety and efficacy of thrombolytic therapy for massive and submassive pulmonary embolism (PE). Methods: A search of human trials in the English-language (September 2017) was conducted through the MEDLINE database using the following terms: PE, tissue plasminogen activator, tenecteplase, and alteplase. 67 unique articles were identified, of which 24 clinical trials discussing clinical outcomes related to administration of either intravenous tenecteplase or alteplase were included. Results: Thrombolytic therapy with anticoagulation significantly reduced mortality compared to anticoagulation alone in massive PE. In submassive PE, thrombolytics reduced the rate of right ventricular dysfunction and hemodynamic collapse; however, there is an increased risk of major and minor bleeding with no benefit on long-term functional outcomes. Conclusions: Patients with massive PE should receive thrombolytics when no major contraindications to therapy exist. Patients with submassive PE at highest risk for progression to hemodynamic instability should receive anticoagulation and be monitored for clinical deterioration. If an imminent risk of hemodynamic instability or cardiac arrest occurs, thrombolytics should be administered if no contraindications exist. Net mortality benefit and risk of bleeding must be considered when deciding to administer thrombolytic therapy in massive or submassive PE.

scholarly journals Letter to the Editor

2021 ◽  
Vol 20 (3) ◽  
pp. 234-234
Author(s):  
N Smallwood ◽  
Keyword(s):  
Pulmonary Embolism ◽  
Thrombolytic Therapy ◽  
Recent Article ◽  
Ventricular Dysfunction ◽  
Right Ventricular Dysfunction ◽  
Haemodynamic Stability ◽  
Submassive Pulmonary Embolism ◽  
Systemic Thrombolytic Therapy ◽  
Nice Guidance ◽  
Potential Benefits

I read the recent article by Apsey et al with interest, which recommended "the potential benefits of thrombolytic therapy in massive and submassive pulmonary embolism". This would appear to go against current NICE guidance which states "Do not offer pharmacological systemic thrombolytic therapy to people with PE and haemodynamic stability with or without right ventricular dysfunction". Both recent NICE and European pulmonary embolism (PE) guidance are clear that only high-risk PE (previously called 'massive') should routinely be thrombolysed.

scholarly journals Submassive Pulmonary Embolism: Current Perspectives and Future Directions

2021 ◽  
Vol 10 (15) ◽  
pp. 3383
Author(s):  
Phillip C. Nguyen ◽  
Hannah Stevens ◽  
Karlheinz Peter ◽  
James D. McFadyen
Keyword(s):  
Pulmonary Embolism ◽  
High Risk ◽  
Thrombolytic Therapy ◽  
Current Evidence ◽  
Conflicting Evidence ◽  
Submassive Pulmonary Embolism ◽  
High Risk Disease ◽  
Systemic Thrombolytic Therapy ◽  
Meta Analyses

Submassive pulmonary embolism (PE) lies on a spectrum of disease severity between standard and high-risk disease. By definition, patients with submassive PE have a worse outcome than the majority of those with standard-risk PE, who are hemodynamically stable and lack imaging or laboratory features of cardiac dysfunction. Systemic thrombolytic therapy has been proven to reduce mortality in patients with high-risk disease; however, its use in submassive PE has not demonstrated a clear benefit, with haemodynamic improvements being offset by excess bleeding. Furthermore, meta-analyses have been confusing, with conflicting results on overall survival and net gain. As such, significant interest remains in optimising thrombolysis, with recent efforts in catheter-based delivery as well as upcoming studies on reduced systemic dosing. Recently, long-term cardiorespiratory limitations following submassive PE have been described, termed post-PE syndrome. Studies on the ability of thrombolytic therapy to prevent this condition also present conflicting evidence. In this review, we aim to clarify the current evidence with respect to submassive PE management, and also to highlight shortcomings in current definitions and prognostic factors. Additionally, we discuss novel therapies currently in preclinical and early clinical trials that may improve outcomes in patients with submassive PE.

Advanced Management Options for Massive and Submassive Pulmonary Embolism

2016 ◽  
Vol 10 (1) ◽  
pp. 30 ◽  
Author(s):  
Sonika Malik ◽  
◽  
Anju Bhardwaj ◽  
Matthew Eisen ◽  
Sanjay Gandhi ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Vena Cava ◽  
Right Ventricular Dysfunction ◽  
Hemodynamic Instability ◽  
Adverse Outcomes ◽  
Intermediate Risk ◽  
Management Options ◽  
Vena Cava Filters ◽  
Submassive Pulmonary Embolism ◽  
Risk Patients

Pulmonary embolism (PE) is an important cause of morbidity and mortality and presents with significant diagnostic and therapeutic challenges. Clinical presentation ranges from mild, nonspecific symptoms to syncope, shock, and sudden death. Patients with hemodynamic instability and/ or signs of right ventricular dysfunction are at high risk for adverse outcomes and may benefit from aggressive therapy and support. Therapeutic anticoagulation is indicated in all patients in the absence of contraindications. Thrombolysis should be strongly considered in selected high- and intermediate-risk patients, either by systemic infusion or percutaneous catheter-directed therapy. Other therapeutic modalities, such as vena cava filters and surgical embolectomy, are options for patients who fail or cannot tolerate anticoagulation and/or thrombolysis. This article reviews the assessment and advanced management options for acute PE with focus on high- and intermediate-risk patients.

scholarly journals Prolonged Chest Compressions during Cardiopulmonary Resuscitation for In-Hospital Cardiac Arrest due to Acute Pulmonary Embolism

2015 ◽  
Vol 42 (2) ◽  
pp. 136-138 ◽  
Author(s):  
Carla Nobre ◽  
Boban Thomas ◽  
Luis Santos ◽  
João Tavares
Keyword(s):  
Pulmonary Embolism ◽  
Thrombolytic Therapy ◽  
Acute Pulmonary Embolism ◽  
Cardiopulmonary Arrest ◽  
Hemodynamic Instability ◽  
Circulatory Support ◽  
Chest Compressions ◽  
Output State ◽  
Dismal Prognosis ◽  
Systemic Thrombolytic Therapy

Patients with hemodynamic collapse due to acute pulmonary embolism have a dismal prognosis if not treated rapidly. Therapeutic options include systemic thrombolytic therapy, rheolytic thrombectomy, and surgical embolectomy. However, the efficacy of thrombolytic therapy is diminished because the low-output state hinders effective delivery of the lytic agent to the thrombus. In the absence of any form of mechanical circulatory support, such as extracorporeal membrane oxygenation or cardiac surgery on site, we think that prolonged vigorous manual compressions might be the only way to support the circulation during the initial critical state, when thrombolytic therapy has been administered. We report the results of prolonged manual chest compressions (exceeding 30 minutes) on 6 patients who received tenecteplase in treatment of acute pulmonary embolism that induced in-hospital cardiopulmonary arrest. Four of 6 patients survived and were discharged from the hospital. In an era of increasing technologic complexity for patients with hemodynamic instability, we emphasize the importance of prolonged chest compressions, which can improve systemic perfusion, counteract the prothrombotic state associated with cardiopulmonary arrest, and give the lytic agent time to act.

scholarly journals Unloading of Right Ventricle and Clinical Improvement after Ultrasound-Accelerated Thrombolysis in Patients with Submassive Pulmonary Embolism

2014 ◽  
Vol 2014 ◽  
pp. 1-8 ◽  
Author(s):  
Sachin Kumar Amruthlal Jain ◽  
Brijesh Patel ◽  
Wadie David ◽  
Ayad Jazrawi ◽  
Patrick Alexander
Keyword(s):  
Pulmonary Embolism ◽  
Right Ventricle ◽  
Right Ventricular ◽  
Case Series ◽  
Hemodynamic Instability ◽  
Acute Setting ◽  
Systemic Thrombolysis ◽  
Increased Risk ◽  
Right Ventricular Strain ◽  
Submassive Pulmonary Embolism

Acute pulmonary embolism (PE) can be devastating. It is classified into three categories based on clinical scenario, elevated biomarkers, radiographic or echocardiographic features of right ventricular strain, and hemodynamic instability. Submassive PE is diagnosed when a patient has elevated biomarkers, CT-scan, or echocardiogram showing right ventricular strain and no signs of hemodynamic compromise. Thromboemboli in the acute setting increase pulmonary vascular resistance by obstruction and vasoconstriction, resulting in pulmonary hypertension. This, further, deteriorates symptoms and hemodynamic status. Studies have shown that elevated biomarkers and right ventricular (RV) dysfunction have been associated with increased risk of mortality. Therefore, aggressive treatment is necessary to “unload” right ventricle. The treatment of submassive PE with thrombolysis is controversial, though recent data have favored thrombolysis over conventional anticoagulants in acute setting. The most feared complication of systemic thrombolysis is intracranial or major bleeding. To circumvent this problem, a newer and safer approach is sought. Ultrasound-accelerated thrombolysis is a relatively newer and safer approach that requires local administration of thrombolytic agents. Herein, we report a case series of five patients who underwent ultrasound-accelerated thrombolysis with notable improvement in symptoms and right ventricular function.

scholarly journals Low-dose urokinase thrombolytic therapy for patients with acute intermediate-high-risk pulmonary embolism: A retrospective cohort study

PLoS ONE ◽  
2021 ◽  
Vol 16 (3) ◽  
pp. e0248603
Author(s):  
Cuilian Weng ◽  
Xincai Wang ◽  
Long Huang ◽  
Xingsheng Lin ◽  
Qinghua Liu
Keyword(s):  
Pulmonary Embolism ◽  
High Risk ◽  
Thrombolytic Therapy ◽  
Anticoagulant Therapy ◽  
Low Dose ◽  
Therapy Group ◽  
Minor Bleeding ◽  
Short Term

Introduction Patients at intermediate-high risk of developing a pulmonary embolism (PE) are very likely to experience adverse outcomes, such as cardiovascular instability and death. The role of thrombolytic therapy in intermediate-high-risk PE remains controversial. Objectives This study aimed to determine the efficacy and safety of low-dose urokinase (UK) thrombolytic therapy for intermediate-high-risk PE. Patients and methods This retrospective study included 81 consecutive patients with intermediate-high-risk PE from two centers. Patients received low-dose UK or low-molecular-weight heparin (anticoagulant therapy group). The efficacy outcomes were mortality, computed tomography pulmonary angiography (CTPA)-confirmed absorption, and dyspnea. Safety was assessed as the incidence of bleedings. Results The in-hospital mortality, 9-month mortality, and long-term mortality at the last follow-up were comparable for the low-dose UK group and the anticoagulant therapy group (6.45% vs. 0%, p = 0.144, 9.68% vs. 8.16%, p = 0.815, and 12.90% vs. 12.24%, p = 0.931, respectively). CTPA-confirmed absorption at one month after admission was higher in the low-dose UK group than in the anticoagulant therapy group (p = 0.016). The incidences of short-term dyspnea at discharge and long-term dyspnea at the last follow-up were lower in the low-dose UK group than in the anticoagulant therapy group (27.59% vs. 52%, p = 0.035, 33.33% vs. 58.14%, p = 0.043, respectively). No major bleeding occurred. The incidence of minor bleeding was not significantly different between the two groups (3.23% vs. 6%, p = 0.974). Conclusion In intermediate-high-risk PE, a low-dose UK might increase CTPA-confirmed absorption and improve short-term and long-term dyspnea without affecting mortality or increasing the bleeding risk.

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