Low-Dose Alteplase for the Treatment of Submassive Pulmonary Embolism: A Case Series

2019 ◽  
Vol 33 (5) ◽  
pp. 708-711 ◽  
Author(s):  
Sara N. Layman ◽  
Tommie J. Guidry ◽  
Amanda R. Gillion
Keyword(s):  
Pulmonary Embolism ◽  
Right Ventricle ◽  
Low Dose ◽  
Case Series ◽  
Bleeding Events ◽  
Efficacious Treatment ◽  
Increased Risk ◽  
Submassive Pulmonary Embolism ◽  
Successful Resolution ◽  
Ventricle Size

Purpose: Pulmonary embolism (PE) can lead to significant morbidity and mortality. Thrombolytics are currently approved for the treatment of massive PE; however, the CHEST guidelines recommend against systemic thrombolytic use in acute PE patients without hypotension, unless these patients deteriorate on anticoagulation alone. Several studies have demonstrated the effectiveness of thrombolysis in submassive PE; however, the full thrombolytic dose resulted in significantly increased risk of non-intracranial bleeding and hemorrhagic stroke. The MOPETT trial demonstrated that low-dose tissue plasminogen activator (tPA) significantly reduced the risk of pulmonary hypertension and recurrent PE compared to anticoagulation alone in submassive PE patients without any bleeding events. Summary: This case series highlights 5 patient cases utilizing low-dose tPA for submassive PE. All patients had successful resolution of their symptoms and improvement in vitals and laboratory values. Furthermore, no patient had any bleeding during or after tPA administration. Three patients showed improved right ventricle function and reduced or normal right ventricle size on echocardiogram after tPA administration. Conclusion: The potential for low-dose tPA as a safe and efficacious treatment option for submassive PE is illustrated by this case series. However, larger, randomized controlled trials are needed to establish low-dose tPA as an accepted treatment modality.

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 Case fatality rate and fatal bleeding complication in patients with pulmonary embolism and patent foramen ovale

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
L Hobohm ◽  
V H Schmitt ◽  
T Munzel ◽  
S V Konstantinides ◽  
K Keller
Keyword(s):  
Pulmonary Embolism ◽  
Patent Foramen Ovale ◽  
Right Atrial ◽  
Foramen Ovale ◽  
Bleeding Events ◽  
Systemic Thrombolysis ◽  
Federal States ◽  
Intracerebral Bleeding ◽  
Increased Risk ◽  
Acute Pe

Abstract Objectives In patients with acute pulmonary embolism (PE), right atrial pressure is elevated, which increases risk for right-to-left shunt when patent foramen ovale (PFO) is present and thus potentially increases risk for paradoxical embolism. Little is known about the clinical outcome of patients with PE and concomitant PFO. Methods We analysed data on patient characteristics, treatments and in-hospital outcomes for all PE patients (ICD-code I26) with concomitant presence of PFO in Germany 2005–2018 (source: Research Data Center (RDC) of the Federal Statistical Office and the Statistical Offices of the federal states, DRG Statistics 2005–2018, and own calculations). Results Between January 2005 and December 2018, 1,174,235 patients with acute PE (53.5% females) were included in this analysis; of those, 5,486 (0.5%) had a concomitant diagnosis of PFO. Trends analysis demonstrating an increasing frequency of diagnosed PE with additional PFO from 2005 (n=299) to 2018 (n=556; p<0.001). While patients with PE and PFO presented more often with signs of haemodynamic compromise such RV dysfunction (37.6% vs. 28.5%) or shock (7.1% vs. 3.9%) as well as paradox arterial emboli (47.8% vs. 3.2%) or intracerebral bleeding (3.3% vs. 0.6%), PE patients with PFO died less often compared to PE patients without PFO (11.1% vs. 15.8%). Patients with PE and PFO were younger (65 [IQR 52–75] vs. 72 [60–80]; P<0.001) and were more often treated invasively with a reperfusion treatment approach like embolectomy (10.2% vs. 4.2%) or systemic thrombolysis (5.0% vs 0.1%). A multivariate logistic regression analysis revealed a 27.6-fold increased risk for paradox arterial emboli (OR, 27.6 [95% CI 26.1–29.1]; p<0.001) and a 3.9-fold increased risk for intracerebral bleeding events (OR, 3.9 [95% CI 3.3–4.54]; p<0.001) for patients with PE and concomitant PFO. In normotensive patients with RVD and PFO, embolectomy were not associated to affect the rate of intracerebral bleeding events (OR, 0.8 [95% CI 0.2–2.6]; p=0.720) compared to conventional non-reperfusion treatment; instead of systemic thrombolysis, which is associated with a higher risk of intracerebral bleeding (OR, 3.5 [95% CI 1.8–6.59]; p<0.001) compared to conventional non-reperfusion treatment. Conclusion Patients with acute PE and the concomitant presence of PFO are associated with a high risk for paradox arterial emboli and intracranial bleeding events. Especially in normotensive patients, the use of systemic thrombolysis should be considered with cautious. Thus, our findings may improve the clinical management of patients with PE and PFO. FUNDunding Acknowledgement Type of funding sources: None.

Risperidone and pulmonary embolism: a harmful association? Case series and review of the literature

2012 ◽  
Vol 24 (6) ◽  
pp. 361-368 ◽  
Author(s):  
Massimo Gallerani ◽  
Davide Imberti ◽  
Elisa Mari ◽  
Anna Marra ◽  
Roberto Manfredini
Keyword(s):  
Pulmonary Embolism ◽  
Hospital Setting ◽  
Case Series ◽  
Bipolar Disorders ◽  
Term Treatment ◽  
Review Of The Literature ◽  
Short Term Treatment ◽  
Atypical Antipsychotic Drug ◽  
Medicine Department ◽  
Increased Risk

Gallerani M, Imberti D, Mari E, Marra A, Manfredini R. Risperidone and pulmonary embolism: a harmful association? Case series and review of the literature.Objective: Risperidone is an atypical antipsychotic drug used to treat a number of psychiatric diseases, such as schizophrenia, schizoaffective and bipolar disorders and irritability in children with autism. Moreover, it is also often administered for short-term treatment of persistent aggression in people with moderate-to-severe Alzheimer's dementia. A possible association between risperidone and venous thromboembolism (VTE) has been described. We intended to verify the dimension of the problem in our hospital setting.Methods: We considered all consecutive patients hospitalised in our Internal Medicine Department from January 2004 to December 2010, who were treated with risperidone and presented pulmonary embolism (PE).Results: Four cases of patients, apparently free from the well-known major risk factors for VTE (i.e. cancer, prolonged immobilisation, acute cardiac and respiratory failure, infections), who presented PE associated with risperidone therapy, were reported in details.Conclusions: A review of the available literature, discussing the possible different pathogenic reasons for this increased risk of VTE, is provided.

scholarly journals Apixaban or Rivaroxaban Versus Warfarin for Treatment of Submassive Pulmonary Embolism After Catheter-Directed Thrombolysis

2018 ◽  
Vol 24 (6) ◽  
pp. 908-913 ◽  
Author(s):  
Lara M. Groetzinger ◽  
Taylor J. Miller ◽  
Ryan M. Rivosecchi ◽  
Roy E. Smith ◽  
Mark T. Gladwin ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Factor Xa ◽  
Multivariate Regression Analysis ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Minor Bleeding ◽  
Bleeding Events ◽  
Catheter Directed Thrombolysis ◽  
Submassive Pulmonary Embolism ◽  
Median Hospital

Background: Little data exist on the use of direct oral anticoagulant (DOAC) factor Xa inhibitors for submassive pulmonary embolism (PE) after catheter-directed thrombolysis (CDT). The objective of this evaluation was to determine whether the transition from parenteral anticoagulation to DOACs for submassive PE after CDT would decrease hospital length of stay (LOS) compared to warfarin. Methods: A retrospective review of patients diagnosed with submassive PE who underwent CDT was conducted from January 1, 2012, to February 28, 2017. Hospital LOS and major and minor bleeding events were recorded during hospitalization and at 90 days. Results: Sixty-two patients met the inclusion criteria, 36 in warfarin group and 26 in the DOAC group. Overall, patients receiving rivaroxaban or apixaban had a shorter median hospital LOS compared to warfarin (4.0 vs 6.1 days, P = .002). In the multivariate regression analysis, administration of DOAC was an independent predictor of decreased hospital LOS, β: −2.1, 95% confidence interval (−3.5 to −0.7). Conclusion: Among patients with submassive PE, initiation of a DOAC shortly after CDT may result in a decreased hospital LOS compared to parenterally bridged warfarin.

Catheter-Directed Thrombolysis versus Systemic Anticoagulation for Submassive Pulmonary Embolism: A Meta-Analysis

2021 ◽  
Vol 17 ◽  
Author(s):  
Juan Arturo Siordia ◽  
Amanpreet Kaur
Keyword(s):  
Pulmonary Embolism ◽  
Major Bleeding ◽  
Meta Analysis ◽  
Current Evidence ◽  
Bleeding Events ◽  
Electronic Search ◽  
Catheter Directed Thrombolysis ◽  
Submassive Pulmonary Embolism ◽  
Systemic Anticoagulation ◽  
One Year

Background: The optimal therapy for submassive pulmonary embolism remains in question. The following meta-analysis compiles the current evidence comparing catheter-directed thrombolysis (CDT) versus systemic anticoagulation (SA). Methods: An electronic search through PubMed and Google scholar revealed studies comparing CDT versus SA in terms of mortality and major bleeding events. 30-day, 90-day, and 1-year mortality results were analyzed. Results: Six studies were included in the meta-analysis. Thirty-day and one-year mortality were less with CDT compared to SA (OR 0.27 [CI 0.11-0.67]; OR 0.50 [CI 0.28-0.89]). Ninety-day mortality was similar between the two methods (OR 0.57 [CI 0.17-1.92]). Compilation of all studies reporting at least greater than 30-day mortality revealed less mortality with CDT (OR 0.51 [0.30-0.86]). Major bleeding was similar between the two treatments (OR 1.63 [CI 0.63-4.20]). Conclusion: CDT has less 30-day and 1-year mortality with equivalent rates of major bleeding compared to SA for treatment of submassive pulmonary embolism.

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.

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