1
|
Rouleau SG, Casey SD, Kabrhel C, Vinson DR, Long B. Management of high-risk pulmonary embolism in the emergency department: A narrative review. Am J Emerg Med 2024; 79:1-11. [PMID: 38330877 DOI: 10.1016/j.ajem.2024.01.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 12/22/2023] [Accepted: 01/30/2024] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND High-risk pulmonary embolism (PE) is a complex, life-threatening condition, and emergency clinicians must be ready to resuscitate and rapidly pursue primary reperfusion therapy. The first-line reperfusion therapy for patients with high-risk PE is systemic thrombolytics (ST). Despite consensus guidelines, only a fraction of eligible patients receive ST for high-risk PE. OBJECTIVE This review provides emergency clinicians with a comprehensive overview of the current evidence regarding the management of high-risk PE with an emphasis on ST and other reperfusion therapies to address the gap between practice and guideline recommendations. DISCUSSION High-risk PE is defined as PE that causes hemodynamic instability. The high mortality rate and dynamic pathophysiology of high-risk PE make it challenging to manage. Initial stabilization of the decompensating patient includes vasopressor administration and supplemental oxygen or high-flow nasal cannula. Primary reperfusion therapy should be pursued for those with high-risk PE, and consensus guidelines recommend the use of ST for high-risk PE based on studies demonstrating benefit. Other options for reperfusion include surgical embolectomy and catheter directed interventions. CONCLUSIONS Emergency clinicians must possess an understanding of high-risk PE including the clinical assessment, pathophysiology, management of hemodynamic instability and respiratory failure, and primary reperfusion therapies.
Collapse
Affiliation(s)
- Samuel G Rouleau
- Department of Emergency Medicine, UC Davis Health, University of California, Davis, Sacramento, CA, United States of America.
| | - Scott D Casey
- Kaiser Permanente Northern California Division of Research, The Permanente Medical Group, Oakland, CA, United States of America; Department of Emergency Medicine, Kaiser Permanente Vallejo Medical Center, Vallejo, CA, United States of America.
| | - Christopher Kabrhel
- Department of Emergency Medicine, Center for Vascular Emergencies, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America.
| | - David R Vinson
- Kaiser Permanente Northern California Division of Research, The Permanente Medical Group, Oakland, CA, United States of America; Department of Emergency Medicine, Kaiser Permanente Roseville Medical Center, Roseville, CA, United States of America.
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, United States of America.
| |
Collapse
|
2
|
Fulton B, Bashir R, Weinberg MD, Lakhter V, Rali P, Pugliese S, Giri J, Kobayashi T. Advanced Treatment of Hemodynamically Unstable Acute Pulmonary Embolism and Clinical Follow-up. Semin Thromb Hemost 2023; 49:785-796. [PMID: 37696292 DOI: 10.1055/s-0043-1772840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
Abstract
High-risk acute pulmonary embolism (PE), defined as acute PE associated with hemodynamic instability, remains a significant contributor to cardiovascular morbidity and mortality in the United States and worldwide. Historically, anticoagulant therapy in addition to systemic thrombolysis has been the mainstays of medical therapy for the majority of patients with high-risk PE. In efforts to reduce the morbidity and mortality, a wide array of interventional and surgical therapies has been developed and employed in the management of these patients. However, the most recent guidelines for the management of PE have reserved the use of these advanced therapies in scenarios where thrombolytic therapy plus anticoagulation are unsuccessful. This is due largely to the lack of prospective, randomized studies in this population. Stemming from this, the approach to treatment of these patients varies widely depending on institutional experience and resources. Furthermore, morbidity and mortality remain unacceptably high in this population, with estimated 30-day mortality of at least 30%. As such, development of a standardized approach to treatment of these patients is paramount to improving outcomes. Early and accurate risk stratification in conjunction with a multidisciplinary team approach in the form of a PE response team is crucial. With the advent of novel therapies for the treatment of acute PE, in addition to the growing availability of and familiarity with mechanical circulatory support systems, such a standardized approach may now be within reach.
Collapse
Affiliation(s)
- Brian Fulton
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Riyaz Bashir
- Division of Cardiovascular Disease, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Mitchell D Weinberg
- Zucker School of Medicine at Hofstra/Northwell, Staten Island University Hospital, Staten Island, New York
| | - Vladimir Lakhter
- Division of Cardiovascular Disease, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Parth Rali
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Steve Pugliese
- Division of Pulmonary and Critical Care Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jay Giri
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
- Cardiovascular Outcomes, Quality and Evaluative Research Center, Philadelphia, Pennsylvania
| | - Taisei Kobayashi
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
- Cardiovascular Outcomes, Quality and Evaluative Research Center, Philadelphia, Pennsylvania
| |
Collapse
|
3
|
Balakrishna AM, Kalathil RAM, Pusapati S, Atreya A, Mehta A, Bansal M, Aggarwal V, Basir MB, Kochar A, Truesdell AG, Vallabhajosyula S. Comparative Outcomes of Catheter-Directed Thrombolysis Plus Systemic Anticoagulation Versus Systemic Anticoagulation Alone in the Management of Intermediate-Risk Pulmonary Embolism in a Systematic Review and Meta-Analysis. Am J Cardiol 2023; 205:249-258. [PMID: 37619491 DOI: 10.1016/j.amjcard.2023.07.170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 07/26/2023] [Accepted: 07/31/2023] [Indexed: 08/26/2023]
Abstract
There are limited and conflicting data on the initial management of intermediate-risk (or submassive) pulmonary embolism (PE). This study sought to compare the outcomes of catheter-directed thrombolysis (CDT) in combination with systemic anticoagulation (SA) to SA alone. A systematic search was conducted in MEDLINE, EMBASE, PubMed, and the Cochrane databases from inception to March 1, 2023 for studies comparing the outcomes of CDT + SA versus SA alone in intermediate-risk PE. The outcomes were in-hospital, 30-day, 90-day, and 1-year mortality; bleeding; blood transfusion; right ventricular recovery; and length of stay. Random-effects models was used to calculate the pooled incidence and risk ratios (RRs) with 95% confidence intervals (CIs). A total of 15 (2 randomized and 13 observational) studies with 10,549 (2,310 CDT + SA and 8,239 SA alone) patients were included. Compared with SA, CDT + SA was associated with significantly lower in-hospital mortality (RR 0.41, 95% CI 0.30 to 0.56, p <0.001), 30-day mortality (RR 0.34, 95% CI 0.18 to 0.67, p = 0.002), 90-day mortality (RR 0.34, 95% CI 0.17 to 0.67, p = 0.002), and 1-year mortality (RR 0.58, 95% CI 0.34 to 0.97, p = 0.04). There were no significant differences between the 2 cohorts in the rates of major bleeding (RR 1.39, 95% CI 0.72 to 2.68, p = 0.56), minor bleeding (RR 1.83, 95% CI 0.97 to 3.46, p = 0.06), and blood transfusion (RR 0.34, 95% CI 0.10 to 1.15, p = 0.08). In conclusion, CDT + SA is associated with significantly lower short-term and long-term all-cause mortality, without any differences in major/minor bleeding, in patients with intermediate-risk PE.
Collapse
Affiliation(s)
| | | | - Suma Pusapati
- Department of Medicine, Creighton University School of Medicine, Omaha, Nebraska
| | - Auras Atreya
- Division of Cardiovascular Medicine, Department of Medicine, University of Arkansas School of Medicine, Little Rock, Arkansas
| | - Aryan Mehta
- Department of Medicine, University of Connecticut School of Medicine, Farmington, Connecticut
| | - Mridul Bansal
- Department of Medicine, East Carolina Brody School of Medicine, Greenville, North Carolina
| | - Vikas Aggarwal
- Section of Cardiovascular Medicine, Department of Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Mir B Basir
- Section of Cardiovascular Medicine, Department of Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Ajar Kochar
- Section of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts
| | | | - Saraschandra Vallabhajosyula
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina.
| |
Collapse
|
4
|
Sadeghipour P, Jenab Y, Moosavi J, Hosseini K, Mohebbi B, Hosseinsabet A, Chatterjee S, Pouraliakbar H, Shirani S, Shishehbor MH, Alizadehasl A, Farrashi M, Rezvani MA, Rafiee F, Jalali A, Rashedi S, Shafe O, Giri J, Monreal M, Jimenez D, Lang I, Maleki M, Goldhaber SZ, Krumholz HM, Piazza G, Bikdeli B. Catheter-Directed Thrombolysis vs Anticoagulation in Patients With Acute Intermediate-High-risk Pulmonary Embolism: The CANARY Randomized Clinical Trial. JAMA Cardiol 2022; 7:1189-1197. [PMID: 36260302 PMCID: PMC9582964 DOI: 10.1001/jamacardio.2022.3591] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 07/22/2022] [Indexed: 01/13/2023]
Abstract
Importance The optimal treatment of intermediate-high-risk pulmonary embolism (PE) remains unknown. Objective To assess the effect of conventional catheter-directed thrombolysis (cCDT) plus anticoagulation vs anticoagulation monotherapy in improving echocardiographic measures of right ventricle (RV) to left ventricle (LV) ratio in acute intermediate-high-risk PE. Design, Setting, and Participants The Catheter-Directed Thrombolysis vs Anticoagulation in Patients with Acute Intermediate-High-Risk Pulmonary Embolism (CANARY) trial was an open-label, randomized clinical trial of patients with intermediate-high-risk PE, conducted in 2 large cardiovascular centers in Tehran, Iran, between December 22, 2018, through February 2, 2020. Interventions Patients were randomly assigned to cCDT (alteplase, 0.5 mg/catheter/h for 24 hours) plus heparin vs anticoagulation monotherapy. Main Outcomes and Measures The proportion of patients with a 3-month echocardiographic RV/LV ratio greater than 0.9, assessed by a core laboratory, was the primary outcome. The proportion of patients with an RV/LV ratio greater than 0.9 at 72 hours after randomization and the 3-month all-cause mortality were among secondary outcomes. Major bleeding (Bleeding Academic Research Consortium type 3 or 5) was the main safety outcome. A clinical events committee, masked to the treatment assignment, adjudicated clinical outcomes. Results The study was prematurely stopped due to the COVID-19 pandemic after recruiting 94 patients (mean [SD] age, 58.4 [2.5] years; 27 women [29%]), of whom 85 patients completed the 3-month echocardiographic follow-up. Overall, 2 of 46 patients (4.3%) in the cCDT group and 5 of 39 patients (12.8%) in the anticoagulation monotherapy group met the primary outcome (odds ratio [OR], 0.31; 95% CI, 0.06-1.69; P = .24). The median (IQR) 3-month RV/LV ratio was significantly lower with cCDT (0.7 [0.6-0.7]) than with anticoagulation (0.8 [0.7-0.9); P = .01). An RV/LV ratio greater than 0.9 at 72 hours after randomization was observed in fewer patients treated with cCDT (13 of 48 [27.0%]) than anticoagulation (24 of 46 [52.1%]; OR, 0.34; 95% CI, 0.14-0.80; P = .01). Fewer patients assigned to cCDT experienced a 3-month composite of death or RV/LV greater than 0.9 (2 of 48 [4.3%] vs 8 of 46 [17.3%]; OR, 0.20; 95% CI, 0.04-1.03; P = .048). One case of nonfatal major gastrointestinal bleeding occurred in the cCDT group. Conclusions and Relevance This prematurely terminated randomized clinical trial of patients with intermediate-high-risk PE was hypothesis-generating for improvement in some efficacy outcomes and acceptable rate of major bleeding for cCDT compared with anticoagulation monotherapy and provided support for a definitive clinical outcomes trial. Trial Registration ClinicalTrials.gov Identifier: NCT05172115.
Collapse
Affiliation(s)
- Parham Sadeghipour
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular, Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
- Clinical Trial Center, Rajaie Cardiovascular, Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Yaser Jenab
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Jamal Moosavi
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular, Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Kaveh Hosseini
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Bahram Mohebbi
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular, Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
- Cardio-Oncology Research Center, Rajaie Cardiovascular, Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Ali Hosseinsabet
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Saurav Chatterjee
- Division of Cardiology, Department of Medicine, Northshore-LIJ Hospitals of Northwell Health, New York, New York
- Zucker School of Medicine, New York, New York
| | - Hamidreza Pouraliakbar
- Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Shapour Shirani
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mehdi H. Shishehbor
- University Hospitals, Harrington Heart and Vascular Institute, Cleveland, Ohio
| | - Azin Alizadehasl
- Cardio-Oncology Research Center, Rajaie Cardiovascular, Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Melody Farrashi
- Echocardiography Research Center, Rajaie Cardiovascular, Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Ali Rezvani
- Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Farnaz Rafiee
- Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Arash Jalali
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Sina Rashedi
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular, Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Omid Shafe
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular, Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Jay Giri
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, Cardiovascular Division, University of Pennsylvania, Philadelphia
| | - Manuel Monreal
- Faculty of Health Sciences, Universidad Católica San Antonio de Murcia, Murcia, Spain
| | - David Jimenez
- Respiratory Department, Hospital Ramón y Cajal, Madrid, Spain
- Medicine Department, Universidad de Alcalá, Madrid, Spain
- CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Irene Lang
- Department of Internal Medicine II, Cardiology and Center of Cardiovascular Medicine, Medical University of Vienna, Vienna, Austria
| | - Majid Maleki
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular, Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Samuel Z. Goldhaber
- Cardiovascular Medicine Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Thrombosis Research Group, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Harlan M. Krumholz
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
- Yale New Haven Hospital Center for Outcomes Research & Evaluation, Yale, New Haven, Connecticut
| | - Gregory Piazza
- Cardiovascular Medicine Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Thrombosis Research Group, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Thrombosis Research Group, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Yale New Haven Hospital Center for Outcomes Research & Evaluation, Yale, New Haven, Connecticut
- Cardiovascular Research Foundation, New York, New York
| |
Collapse
|
5
|
Polaková E, Veselka J. Management of Massive Pulmonary Embolism. Int J Angiol 2022; 31:194-197. [PMID: 36157097 PMCID: PMC9507601 DOI: 10.1055/s-0042-1756176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
Pulmonary embolism is a potentially lethal manifestation of venous thromboembolic disease. It is one of the three main causes of cardiovascular morbidity and mortality in developed countries. Over the years, better diagnostic and risk stratification measures were implemented. A generous range of new treatment options is becoming available, particularly for management of massive pulmonary embolism. Nonetheless, clinicians often face uncertainty in clinical practice due to lack of scientific support for available treatment options. The aim of this article is to review management of massive pulmonary embolism.
Collapse
Affiliation(s)
- Eva Polaková
- Department of Cardiology, Second Medical School, Charles University, Motol University Hospital, Prague, Czech Republic
| | - Josef Veselka
- Department of Cardiology, Second Medical School, Charles University, Motol University Hospital, Prague, Czech Republic
| |
Collapse
|
6
|
Bishay VL, Adenikinju O, Todd R. FlowTriever Retrieval System for the treatment of pulmonary embolism: overview of its safety and efficacy. Expert Rev Med Devices 2021; 18:1039-1048. [PMID: 34530650 DOI: 10.1080/17434440.2021.1982379] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Pulmonary embolism (PE) is the third leading cause of cardiovascular mortality. There has been little change in PE mortality rates over the past two decades making this an appealing area for innovation and development. AREAS COVERED While anticoagulation (AC) and systemic thrombolysis (ST) are the mainstay treatments for high-risk PE and intermediate-high-risk PE with decompensation, advancements in catheter- based therapies offer potential alternatives. Areas covered here will include present guidelines for PE treatment and the landscape of catheter-directed therapies with a focus on the FlowTriever (FT) Retrieval System. Available safety and efficacy data will be reviewed. An online search via Google Scholar and PubMed with the keywords INARI Flowtriever, venous thromboembolism, and pulmonary embolism, alongside bibliographies of published articles, was undertaken as a review of the literature on the FlowTriever system for this device overview. EXPERT OPINION The five-year outlook on the role of catheter-directed therapies in the management of PE includes continued innovation in catheter-directed therapies and a number of high-quality trials on the horizon.
Collapse
Affiliation(s)
- Vivian L Bishay
- Icahn School of Medicine, Mount Sinai Health System, New York, NY, USA
| | | | - Rachel Todd
- Icahn School of Medicine, Mount Sinai Health System, New York, NY, USA
| |
Collapse
|
7
|
Abstract
BACKGROUND Thrombolytic therapy is usually reserved for people with clinically serious or massive pulmonary embolism (PE). Evidence suggests that thrombolytic agents may dissolve blood clots more rapidly than heparin and may reduce the death rate associated with PE. However, there are still concerns about the possible risk of adverse effects of thrombolytic therapy, such as major or minor haemorrhage. This is the fourth update of the Cochrane review first published in 2006. OBJECTIVES To assess the effects of thrombolytic therapy for acute pulmonary embolism. SEARCH METHODS The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL databases and the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 17 August 2020. We undertook reference checking to identify additional studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared thrombolytic therapy followed by heparin versus heparin alone, heparin plus placebo, or surgical intervention for people with acute PE (massive/submassive). We did not include trials comparing two different thrombolytic agents or different doses of the same thrombolytic drug. DATA COLLECTION AND ANALYSIS Two review authors (ZZ, QH) assessed the eligibility and risk of bias of trials and extracted data. We calculated effect estimates using the odds ratio (OR) with a 95% confidence interval (CI) or the mean difference (MD) with a 95% CI. The primary outcomes of interest were death, recurrence of PE and haemorrhagic events. We assessed the certainty of the evidence using GRADE criteria. MAIN RESULTS We identified three new studies for inclusion in this update. We included 21 trials in the review, with a total of 2401 participants. No studies compared thrombolytics versus surgical intervention. We were not able to include one study in the meta-analysis because it provided no extractable data. Most studies carried a high or unclear risk of bias related to randomisation and blinding. Meta-analysis showed that, compared to control (heparin alone or heparin plus placebo), thrombolytics plus heparin probably reduce both the odds of death (OR 0.58, 95% CI 0.38 to 0.88; 19 studies, 2319 participants; low-certainty evidence), and recurrence of PE (OR 0.54, 95% CI 0.32 to 0.91; 12 studies, 2050 participants; low-certainty evidence). Effects on mortality weakened when six studies at high risk of bias were excluded from analysis (OR 0.71, 95% CI 0.45 to 1.13; 13 studies, 2046 participants) and in the analysis of submassive PE participants (OR 0.61, 95% CI 0.37 to 1.02; 1993 participants). Effects on recurrence of PE also weakened after removing one study at high risk of bias for sensitivity analysis (OR 0.60, 95% CI 0.35 to 1.04; 11 studies, 1949 participants). We downgraded the certainty of evidence to low because of 'Risk of bias' concerns. Major haemorrhagic events were probably more common in the thrombolytics group than in the control group (OR 2.84, 95% CI 1.92 to 4.20; 15 studies, 2101 participants; moderate-certainty evidence), as were minor haemorrhagic events (OR 2.97, 95% CI 1.66 to 5.30; 13 studies,1757 participants; low-certainty evidence). We downgraded the certainty of the evidence to moderate or low because of 'Risk of bias' concerns and inconsistency. Haemorrhagic stroke may occur more often in the thrombolytics group than in the control group (OR 7.59, 95% CI 1.38 to 41.72; 2 studies, 1091 participants). Limited data indicated that thrombolytics may benefit haemodynamic outcomes, perfusion lung scanning, pulmonary angiogram assessment, echocardiograms, pulmonary hypertension, coagulation parameters, composite clinical outcomes, need for escalation and survival time to a greater extent than heparin alone. However, the heterogeneity of the studies and the small number of participants involved warrant caution when interpreting results. The length of hospital stay was shorter in the thrombolytics group than in the control group (mean difference (MD) -1.40 days, 95% CI -2.69 to -0.11; 5 studies, 368 participants). Haemodynamic decompensation may occur less in the thrombolytics group than in the control group (OR 0.36, 95% CI 0.20 to 0.66; 3 studies, 1157 participants). Quality of life was similar between the two treatment groups. None of the included studies provided data on post-thrombotic syndrome or on cost comparison. AUTHORS' CONCLUSIONS Low-certainty evidence suggests that thrombolytics may reduce death following acute pulmonary embolism compared with heparin (the effectiveness was mainly driven by one trial with massive PE). Thrombolytic therapy may be helpful in reducing the recurrence of pulmonary emboli but may cause more major and minor haemorrhagic events, including haemorrhagic stroke. More studies of high methodological quality are needed to assess safety and cost effectiveness of thrombolytic therapy for people with pulmonary embolism.
Collapse
Affiliation(s)
- Zhiliang Zuo
- The Center of Gerontology and Geriatrics, West China Hospital, Sichuan University, Chengdu, China
- National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Jirong Yue
- The Center of Gerontology and Geriatrics, West China Hospital, Sichuan University, Chengdu, China
- National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Bi Rong Dong
- The Center of Gerontology and Geriatrics, West China Hospital, Sichuan University, Chengdu, China
- National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Taixiang Wu
- Chinese Clinical Trial Registry, Chinese Ethics Committee of Registering Clinical Trials, West China Hospital, Sichuan University, Chengdu, China
| | - Guan J Liu
- Cochrane China, West China Hospital, Sichuan University, Chengdu, China
| | - Qiukui Hao
- The Center of Gerontology and Geriatrics, West China Hospital, Sichuan University, Chengdu, China
- National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| |
Collapse
|
8
|
Panahi L, Udeani G, Horseman M, Weston J, Samuel N, Joseph M, Mora A, Bazan D. Review of Medical Therapies for the Management of Pulmonary Embolism. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:110. [PMID: 33530544 PMCID: PMC7912594 DOI: 10.3390/medicina57020110] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 01/11/2021] [Accepted: 01/13/2021] [Indexed: 12/12/2022]
Abstract
Traditionally, the management of patients with pulmonary embolism has been accomplished with anticoagulant treatment with parenteral heparins and oral vitamin K antagonists. Although the administration of heparins and oral vitamin K antagonists still plays a role in pulmonary embolism management, the use of these therapies are limited due to other options now available. This is due to their toxicity profile, clearance limitations, and many interactions with other medications and nutrients. The emergence of direct oral anticoagulation therapies has led to more options now being available to manage pulmonary embolism in inpatient and outpatient settings conveniently. These oral therapeutic options have opened up opportunities for safe and effective pulmonary embolism management, as more evidence and research is now available about reversal agents and monitoring parameters. The evolution of the pharmacological management of pulmonary embolism has provided us with better understanding regarding the selection of anticoagulants. There is also a better understanding and employment of anticoagulants in pulmonary embolism in special populations, such as patients with liver failure, renal failure, malignancy, and COVID-19.
Collapse
Affiliation(s)
- Ladan Panahi
- Department of Pharmacy Practice, Texas A&M Rangel College of Pharmacy, 1010 W Ave B, Kingsville, TX 78363, USA; (M.H.); (J.W.); (N.S.); (M.J.); (A.M.); (D.B.)
| | - George Udeani
- Department of Pharmacy Practice, Texas A&M Rangel College of Pharmacy, 1010 W Ave B, Kingsville, TX 78363, USA; (M.H.); (J.W.); (N.S.); (M.J.); (A.M.); (D.B.)
| | | | | | | | | | | | | |
Collapse
|
9
|
Prevention, diagnosis, and management of venous thromboembolism in the critically ill surgical and trauma patient. Curr Opin Crit Care 2021; 26:640-647. [PMID: 33027148 DOI: 10.1097/mcc.0000000000000771] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Venous thromboembolism (VTE), which encompasses deep vein thrombosis and pulmonary embolism, is common among trauma patients and critically ill surgical patients admitted to the ICU. Critical care surgical patients are at an extremely high risk for VTE and the related morbidity and mortality associated with it. The present review aims to provide an overview of the importance of identifying risk factors, prescribing effective prohylaxis, accurate diagnosis, and timely appropriate treatment for trauma and critically ill surgical patients with VTE in the ICU. RECENT FINDINGS VTE is a healthcare burden among critically ill surgical patients that is mostly preventable through adherence to prophylactic protocols that aim to recognize VTE risk factors while simultaneously providing guidance to appropriate timing and administration prophylaxis regimens. Newer pharmacologic therapies for prophylaxis and treatment, diagnostic modalities, and indications for therapy of VTE have continued to evolve. SUMMARY Critical care surgical and trauma patients represent a population that are at a heightened risk for VTE and associated complications. Appropriate screening, prevention strategies, accurate diagnosis, and timely administration of appropriate treatment must be utilized to reduce morbidity and mortality.
Collapse
|
10
|
Mojibian HR, Chow E, Pollak J. FlowTriever System for mechanical thromboembolectomy. Future Cardiol 2020; 17:585-592. [PMID: 33084387 DOI: 10.2217/fca-2020-0104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The systemic or catheter-directed infusion of thrombolytics benefits patients with massive and probably submassive pulmonary embolism. However, the risk of bleeding may offset benefits in a substantial number of patients. Percutaneous mechanical thromboembolectomy is an alternative to thrombolysis in those patients with contraindications to the lytic therapy, also potentially a way to avoid systemic or catheter-directed infusion of the thrombolytic all together. The Inari FlowTriever System (Inari Medical Inc, CA, USA) is the first US FDA-cleared large-bore aspiration thrombectomy device with pulmonary embolism thrombectomy indication. This article is a review of the FlowTriever System, its clinical use, current supportive literates and future research directions.
Collapse
Affiliation(s)
- Hamid R Mojibian
- Department of Radiology & Biomedical Imaging, Section of Vascular & Interventional Radiology, Yale University School of Medicine, New Haven, CT 06510, USA
| | - Eric Chow
- Department of Radiology & Biomedical Imaging, Section of Vascular & Interventional Radiology, Yale University School of Medicine, New Haven, CT 06510, USA
| | - Jeffery Pollak
- Department of Radiology & Biomedical Imaging, Section of Vascular & Interventional Radiology, Yale University School of Medicine, New Haven, CT 06510, USA
| |
Collapse
|
11
|
Delmas C, Aissaoui N, Meneveau N, Bouvaist H, Rousseau H, Puymirat E, Sapoval M, Flecher E, Meyer G, Sanchez O, Del Giudice C, Roubille F, Bonello L. Reperfusion therapies in pulmonary embolism-state of the art and expert opinion: A position paper from the "Unité de Soins Intensifs de Cardiologie" group of the French Society of Cardiology. Arch Cardiovasc Dis 2020; 113:749-759. [PMID: 32978090 DOI: 10.1016/j.acvd.2020.06.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 06/02/2020] [Accepted: 06/04/2020] [Indexed: 01/21/2023]
Abstract
Acute pulmonary embolism is a frequent cardiovascular emergency with an increasing incidence. The prognosis of patients with high-risk and intermediate-high-risk pulmonary embolism has not improved over the last decade. The current treatment strategies are mainly based on anticoagulation to prevent recurrence and reduce pulmonary vasculature obstruction. However, the slow rate of thrombus lysis under anticoagulation is unable to acutely decrease right ventricle overload and pulmonary vasculature resistance in patients with severe obstruction and right ventricle dysfunction. Therefore, patients with high-risk and intermediate-high-risk pulmonary embolism remain a therapeutic challenge. Reperfusion therapies may be discussed for these patients, and include systemic thrombolysis, catheter-directed therapies and surgical thrombectomy. High-risk patients require systemic thrombolysis, but may have contraindications as a result of the high risk of bleeding. In addition, intermediate-high-risk patients should not receive systemic thrombolysis, despite its high efficacy, because of prohibitive bleeding complications. Recently, percutaneous reperfusion techniques have been developed to acutely decrease pulmonary vascular obstruction with lower-dose or no thrombolytic agents and, thus, potentially higher safety than systemic thrombolysis. Some of these techniques improve key haemodynamic variables. Cardiac surgical techniques and venoarterial extracorporeal membrane oxygenation as temporary circulatory support may be useful in selected cases. The development of pulmonary embolism centres with multidisciplinary pulmonary embolism teams is mandatory to enable adequate use of reperfusion and improve outcomes. We aim to present the state of the art regarding reperfusion therapies in pulmonary embolism, but also to provide guidance on their indications and patient selection.
Collapse
Affiliation(s)
- Clément Delmas
- Intensive Cardiac Care Unit, Rangueil University Hospital, Inserm UMR 1048, Institute of Metabolic and Cardiovascular Diseases (I2MC), 31432 Toulouse, France
| | - Nadia Aissaoui
- Critical Care Unit, Penn State Heart and Vascular Institute (HVI), Hershey Medical Center (HMC) and Penn State University, 17033 PA, USA; Inserm U970, Paris Cardiovascular Research Centre, Hôpital Européen George Pompidou, AP-HP, 75015 Paris, France
| | - Nicolas Meneveau
- Department of Cardiology, EA3920, University Hospital Jean Minjoz, 25000 Besancon, France
| | - Helene Bouvaist
- Department of Cardiology, Pôle Thorax et Vaisseaux, CHU Grenoble Alpes, 38700 La Tronche, France
| | - Hervé Rousseau
- Department of Radiology, Hôpital Rangueil 1, CHU de Toulouse, 31059 Toulouse, France
| | - Etienne Puymirat
- Intensive Cardiac Care Unit, Department of Cardiology, Hôpital Européen Georges Pompidou, AP-HP, 75015 Paris, France
| | - Marc Sapoval
- Vascular and Oncological Interventional Radiology, Inserm U970, Paris Cardiovascular Research Centre, Hôpital Européen Georges Pompidou, AP-HP, 75015 Paris, France
| | - Erwan Flecher
- Department of Thoracic and Cardiovascular Surgery, Pontchaillou University Hospital, Inserm UMR 1099, 35000 Rennes, France
| | - Guy Meyer
- Department of Pneumology, Hôpital Européen Georges Pompidou, AP-HP, Université de Paris and CIC 1418, 75015 Paris, France
| | - Olivier Sanchez
- Department of Pulmonology and Intensive Care, Hôpital Européen Georges Pompidou, AP-HP, Inserm UMRS 1140, Université de Paris, 75270 Paris, France
| | - Costantino Del Giudice
- Vascular and Oncological Interventional Radiology, Inserm U970, Paris Cardiovascular Research Centre, Hôpital Européen Georges Pompidou, AP-HP, 75015 Paris, France
| | - François Roubille
- Department of Cardiology, CHU de Montpellier, Université de Montpellier, Inserm, CNRS, 34295 Montpellier, France
| | - Laurent Bonello
- Intensive Care Unit, Department of Cardiology, Hôpital Nord, AP-HM, Aix-Marseille Université, 13015 Marseille; Mediterranean Association for Research and Studies in Cardiology (MARS Cardio), 13000 Marseille, France; INSERM 1263, 1260, Centre for Cardiovascular and Nutrition Research (C2VN), INRA, 13385 Marseille, France.
| |
Collapse
|
12
|
Hong Son PD, Uoc NH, Lu PH, Hung DQ, Vo HL. Surgical pulmonary embolectomy in a multi-trauma patient: One-center experience in the resource-limited setting. SAGE Open Med Case Rep 2020; 8:2050313X20953753. [PMID: 32922799 PMCID: PMC7457691 DOI: 10.1177/2050313x20953753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 08/09/2020] [Indexed: 11/16/2022] Open
Abstract
Pulmonary embolism, a serious complication after trauma, may cause sudden death. We discuss an unusual case of 65-year-old woman who had traffic accident with liver injury and open fracture of both tibia and fibula on the right side. She was diagnosed with massive pulmonary embolism on the second day after accident and successfully underwent emergency surgical embolectomy from bilateral pulmonary arteries. There were no postoperative complications. The patient's good state of health was recorded after 13 months of surgery. Surgical pulmonary embolectomy for such a multi-trauma patient provides valuable experience not only for our institution but also for the countries having similar resource-limited conditions.
Collapse
Affiliation(s)
- Phung Duy Hong Son
- Department of Cardiovascular and Thoracic Surgery, Viet Duc University Hospital, Hanoi, Vietnam.,Hanoi Medical University, Hanoi, Vietnam
| | - Nguyen Huu Uoc
- Department of Cardiovascular and Thoracic Surgery, Viet Duc University Hospital, Hanoi, Vietnam.,Hanoi Medical University, Hanoi, Vietnam
| | - Pham Huu Lu
- Department of Cardiovascular and Thoracic Surgery, Viet Duc University Hospital, Hanoi, Vietnam
| | - Doan Quoc Hung
- Department of Cardiovascular and Thoracic Surgery, Viet Duc University Hospital, Hanoi, Vietnam.,Hanoi Medical University, Hanoi, Vietnam
| | - Hoang-Long Vo
- Institute for Preventive Medicine and Public Health, Hanoi Medical University, Hanoi, Vietnam.,Institute of Health Economics and Technology, Hanoi, Vietnam
| |
Collapse
|
13
|
Rivera-Lebron B, McDaniel M, Ahrar K, Alrifai A, Dudzinski DM, Fanola C, Blais D, Janicke D, Melamed R, Mohrien K, Rozycki E, Ross CB, Klein AJ, Rali P, Teman NR, Yarboro L, Ichinose E, Sharma AM, Bartos JA, Elder M, Keeling B, Palevsky H, Naydenov S, Sen P, Amoroso N, Rodriguez-Lopez JM, Davis GA, Rosovsky R, Rosenfield K, Kabrhel C, Horowitz J, Giri JS, Tapson V, Channick R. Diagnosis, Treatment and Follow Up of Acute Pulmonary Embolism: Consensus Practice from the PERT Consortium. Clin Appl Thromb Hemost 2019; 25:1076029619853037. [PMID: 31185730 PMCID: PMC6714903 DOI: 10.1177/1076029619853037] [Citation(s) in RCA: 129] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Pulmonary embolism (PE) is a life-threatening condition and a leading cause of morbidity and mortality. There have been many advances in the field of PE in the last few years, requiring a careful assessment of their impact on patient care. However, variations in recommendations by different clinical guidelines, as well as lack of robust clinical trials, make clinical decisions challenging. The Pulmonary Embolism Response Team Consortium is an international association created to advance the diagnosis, treatment, and outcomes of patients with PE. In this consensus practice document, we provide a comprehensive review of the diagnosis, treatment, and follow-up of acute PE, including both clinical data and consensus opinion to provide guidance for clinicians caring for these patients.
Collapse
Affiliation(s)
| | | | - Kamran Ahrar
- 3 The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Abdulah Alrifai
- 4 University of Miami of Palm Beach Regional Campus/JFK Hospital, Atlantis, FL, USA
| | - David M Dudzinski
- 5 Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Danielle Blais
- 7 The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | - Roman Melamed
- 9 Abbott Northwestern Hospital, Minneapolis, MN, USA
| | | | - Elizabeth Rozycki
- 7 The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | | | - Parth Rali
- 10 Temple University, Philadelphia, PA, USA
| | | | | | | | | | | | - Mahir Elder
- 14 Wayne State University, Detroit, MI, USA.,15 Michigan State University, East Lansing, MI, USA
| | | | | | | | | | | | | | | | - Rachel Rosovsky
- 5 Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Kenneth Rosenfield
- 5 Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | | | - Jay S Giri
- 16 University of Pennsylvania, Philadelphia, PA, USA
| | - Victor Tapson
- 21 Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | | | | |
Collapse
|
14
|
[What are the indications and options for vascular reperfusion in the acute phase of pulmonary embolism?]. Rev Mal Respir 2019; 38 Suppl 1:e53-e58. [PMID: 31585780 DOI: 10.1016/j.rmr.2019.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
|
15
|
Kodým M. Pulmonary embolism cohort in Pisek Hospital. COR ET VASA 2019. [DOI: 10.1016/j.crvasa.2018.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
|
16
|
Pissarra AJ, Malheiro M, Gouveia C, Vicente P, Matos L. Safety of Thrombolysis in a Patient with an Intracranial Dural Arteriovenous Fistula. Eur J Case Rep Intern Med 2019; 6:001019. [PMID: 30756076 DOI: 10.12890/2019_001019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 12/24/2018] [Indexed: 02/03/2023] Open
Abstract
Intracranial dural arteriovenous fistula is an abnormal connection between an artery and a vein that has an increased risk of bleeding. This case report presents a 53-year-old man diagnosed with a dural arteriovenous malformation fistula in occipital topography, lacking therapeutic indication because of an extension. He was admitted to an intensive care unit due to a high-risk pulmonary thromboembolism with indication for thrombolysis. Taking into account the hemorrhagic risk associated with arteriovenous malformation, the authors discuss the therapeutic options and the inherent risks. LEARNING POINTS Intracranial dural arteriovenous fistulas are pathologic shunts between dural arteries and veins that have an inherent risk of intracranial hemorrhage.Systemic thrombolytic agents are a therapeutic option for high-risk pulmonary thromboembolism. Their potential benefits outweigh the risk of life-threatening bleeding; however, careful patient risk stratification should be performed and other options, such as surgical embolectomy or percutaneous catheter-directed treatment, should be considered if available.Multidisciplinarity is the key to better therapeutic decisions and the patient's opinion should always be taken into account.
Collapse
Affiliation(s)
- Ana João Pissarra
- Medical Oncology Department, Hospital São Francisco Xavier, Lisbon, Portugal
| | - Mariana Malheiro
- Medical Oncology Department, Hospital São Francisco Xavier, Lisbon, Portugal
| | - Carolina Gouveia
- Internal Medicine Department, Hospital São Francisco Xavier, Lisbon, Portugal
| | - Patrícia Vicente
- Internal Medicine Department, Hospital São Francisco Xavier, Lisbon, Portugal
| | - Leonor Matos
- Medical Oncology Department, Hospital São Francisco Xavier, Lisbon, Portugal
| |
Collapse
|
17
|
Khorev NG, Beller AV, Borovikov ÉV, Kon'kova VO, Shoĭkhet IN. [Comparative efficacy of various thrombolytic agents in treatment of pulmonary embolism]. ANGIOLOGIIA I SOSUDISTAIA KHIRURGIIA = ANGIOLOGY AND VASCULAR SURGERY 2019; 25:23-28. [PMID: 31503244 DOI: 10.33529/angi02019316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
The authors carried out a retrospective analysis of clinical efficacy of streptokinase and alteplase (actilyse®) in patients presenting with high- and intermediate-to-high risk pulmonary artery thromboembolism (PATE) who were discharged from hospital after appropriate treatment performed. Of the total number of the treated patients, we formed 2 groups comprising 20 patients each, receiving alteplase (group 1) and streptokinase (group 2). The patients were comparable by the main clinical characteristics, predisposing factors, severity of pulmonary artery thromboembolism (PATE) and duration of treatment. Efficacy of thrombolytic therapy assessed clinically and instrumentally did not differ. However, by the stratified risk and frequency of PATE relapses, the condition of patients receiving alteplase turned out to be more severe. Based on the obtained results, a conclusion was made that actilyse is a drug of choice for treatment of patients with PATE.
Collapse
Affiliation(s)
- N G Khorev
- Altai State Medical University of the RF Ministry of Public Health, Barnaul, Russia; Departmental Clinical Hospital at the Barnaul Station of the Open Joint Stock Company 'Russian Railways', Barnaul, Russia
| | - A V Beller
- Departmental Clinical Hospital at the Barnaul Station of the Open Joint Stock Company 'Russian Railways', Barnaul, Russia
| | | | - V O Kon'kova
- Altai State Medical University of the RF Ministry of Public Health, Barnaul, Russia; Municipal Hospital #5, Barnaul, Russia
| | - Ia N Shoĭkhet
- Altai State Medical University of the RF Ministry of Public Health, Barnaul, Russia
| |
Collapse
|
18
|
Abstract
BACKGROUND Thrombolytic therapy is usually reserved for patients with clinically serious or massive pulmonary embolism (PE). Evidence suggests that thrombolytic agents may dissolve blood clots more rapidly than heparin and may reduce the death rate associated with PE. However, there are still concerns about the possible risk of adverse effects of thrombolytic therapy, such as major or minor haemorrhage. This is the third update of the Cochrane review first published in 2006. OBJECTIVES To assess the effects of thrombolytic therapy for acute pulmonary embolism. SEARCH METHODS The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL databases and the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 16 April 2018. We undertook reference checking to identify additional studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared thrombolytic therapy followed by heparin versus heparin alone, heparin plus placebo, or surgical intervention for patients with acute PE. We did not include trials comparing two different thrombolytic agents or different doses of the same thrombolytic drug. DATA COLLECTION AND ANALYSIS Two review authors (JY, QH) assessed the eligibility and quality of trials and extracted data. We calculated effect estimates using the odds ratio (OR) with 95% confidence interval (CI) or the mean difference (MD) with 95% CI. We assessed the quality of the evidence using GRADE criteria. MAIN RESULTS We identified no new studies for inclusion in this 2018 update. We included in the review 18 trials with a total of 2197 participants. We were not able to include one study in the meta-analysis because it provided no data that we could extract. Most of the studies carried a high risk of bias because of high or unclear risk related to randomisation and blinding. Meta-analysis showed that, compared with heparin alone, or heparin plus placebo, thrombolytics plus heparin can reduce the odds of death (OR 0.57, 95% CI 0.37 to 0.87, 2167 participants, P = 0.01, low-quality evidence) and recurrence of PE (OR 0.51, 95% CI 0.29 to 0.89, 1898 participants, P = 0.02, low-quality evidence). Effects on mortality weakened when we excluded from analysis four studies at high risk of bias (OR 0.66, 95% CI 0.42 to 1.06, 2054 participants, P = 0.08). The incidence of major and minor haemorrhagic events was higher in the thrombolytics group than in the control group (OR 2.90, 95% CI 1.95 to 4.31, 1897 participants, P < 0.001, low-quality evidence; OR 3.09, 95% CI 1.58 to 6.06, 1553 participants, P = 0.001, very low-quality evidence, respectively). We downgraded the quality of the evidence to low or very low because of design limitations, potential influence of pharmaceutical companies, and small sample sizes. Length of hospital stay (mean difference (MD) -0.89, 95% CI -3.13 to 1.34) and quality of life were similar between the two treatment groups. Limited information from a small number of trials indicated that thrombolytics may improve haemodynamic outcomes, perfusion lung scanning, pulmonary angiogram assessment, echocardiograms, pulmonary hypertension, coagulation parameters, clinical outcomes, and survival time to a greater extent than heparin alone. However, the heterogeneity of the studies and the small number of participants involved warrant caution when results are interpreted. Similarily, fewer participants from the thrombolytics group required escalation of treatment. None of the included studies reported on post-thrombotic syndrome or compared the costs of different treatments. AUTHORS' CONCLUSIONS Low-quality evidence suggests that thrombolytics reduce death following acute pulmonary embolism compared with heparin. The included studies used a variety of thrombolytic drugs. Thrombolytic therapy may be helpful in reducing the recurrence of pulmonary emboli but may cause major and minor haemorrhagic events and stroke. More high-quality, blinded randomised controlled trials assessing safety and cost-effectiveness of therapies for pulmonary embolism are required.
Collapse
Affiliation(s)
- Qiukui Hao
- West China Hospital, Sichuan UniversityThe Center of Gerontology and GeriatricsNo. 37, Guo Xue XiangChengduSichuanChina610041
| | - Bi Rong Dong
- West China Hospital, Sichuan UniversityThe Center of Gerontology and GeriatricsNo. 37, Guo Xue XiangChengduSichuanChina610041
| | - Jirong Yue
- West China Hospital, Sichuan UniversityThe Center of Gerontology and GeriatricsNo. 37, Guo Xue XiangChengduSichuanChina610041
| | - Taixiang Wu
- West China Hospital, Sichuan UniversityChinese Clinical Trial Registry, Chinese Ethics Committee of Registering Clinical TrialsNo. 37, Guo Xue XiangChengduSichuanChina610041
| | - Guan J Liu
- West China Hospital, Sichuan UniversityCochrane ChinaNo. 37, Guo Xue XiangChengduSichuanChina610041
| | | |
Collapse
|
19
|
Lozier JN, Elinoff JM, Suffredini AF, Rosing DR, Sidenko S, Sherry RM, Metwalli AR, Sachdev V, Danner RL, Chang R. Low-dose, short course alteplase treatment of submassive pulmonary embolism: a case series from the National Institutes of Health Clinical Center. Blood Coagul Fibrinolysis 2018; 29:701-707. [PMID: 30300148 PMCID: PMC10831663 DOI: 10.1097/mbc.0000000000000774] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
: Guidelines-recommend thrombolytic therapy for pulmonary embolism in patients with severe hemodynamic compromise and low risk of bleeding. Thrombolytics in submassive pulmonary embolism have an unfavorable risk/benefit ratio and remain controversial. Based on our experience with extensive, lower extremity thrombi, nine patients with symptomatic, submassive pulmonary embolisms (five medical, four surgical) were treated with low-dose alteplase (<10 mg/day, infused over 6 h per treatment). Alteplase was delivered by pulse spray and/or directed or undirected central venous catheters depending on clot size and location. All patients improved symptomatically and as determined objectively by pulmonary artery pressures and/or imaging, though acute benefits ranged from substantial to modest. One surgical patient required re-exploration for bleeding at the site of a recent retroperitoneal lymph node dissection. This experience may help guide the design of a randomized controlled trial to determine the safety and efficacy of low-dose alteplase for submassive pulmonary embolism.
Collapse
Affiliation(s)
- Jay N. Lozier
- Office of Tissues and Advanced Therapies, FDA Center for Biologics Evaluation and Research, Silver Spring
| | - Jason M. Elinoff
- Critical Care Medicine Department, National Institutes of Health Clinical Center
| | | | | | | | - Richard M. Sherry
- Surgery Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Adam R. Metwalli
- Urologic Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
- Division of Urology, Department of Surgery, Howard University Hospital, Washington, District of Columbia
| | - Vandana Sachdev
- Cardiovascular Branch, National Heart, Lung, and Blood Institute
| | - Robert L. Danner
- Critical Care Medicine Department, National Institutes of Health Clinical Center
| | - Richard Chang
- Department of Radiologic Diagnostics, National Institutes of Health Clinical Center, Bethesda, Maryland, USA
| |
Collapse
|
20
|
Reardon PM, Yadav K, Hendin A, Karovitch A, Hickey M. Contemporary Management of the High-Risk Pulmonary Embolism: The Clot Thickens. J Intensive Care Med 2018; 34:603-608. [DOI: 10.1177/0885066618789879] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Pulmonary embolism (PE) is a common disease process encountered in the acute care setting. It presents on a spectrum of severity with the most severe presentations carrying a substantial risk of morbidity and mortality. In recent years, a wide range of competing treatment strategies have been proposed for the high-risk PE including new catheter-based and extracorporeal techniques, and management has become more challenging. There is currently no consensus as to the optimal approach to treatment. Contemporary management decisions are informed by the balance between the risk of deterioration and the risk of harm from intervention, within the available resources. This review will summarize the current evidence to better inform clinical decision-making in high-risk PE and highlight future directions in management.
Collapse
Affiliation(s)
- Peter M. Reardon
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Krishan Yadav
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Ariel Hendin
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Alan Karovitch
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Michael Hickey
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| |
Collapse
|
21
|
Schultz J, Andersen A, Gade IL, Ringgaard S, Kjaergaard B, Nielsen-Kudsk JE. A porcine in-vivo model of acute pulmonary embolism. Pulm Circ 2018; 8:2045893217738217. [PMID: 28971735 PMCID: PMC5798692 DOI: 10.1177/2045893217738217] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 10/01/2017] [Indexed: 11/16/2022] Open
Abstract
Acute pulmonary embolism (PE) is the third most common cardiovascular cause of death after acute myocardial infarction and stroke. Patients are, however, often under-treated due to the risks associated with systemic thrombolysis and surgical embolectomy. Novel pharmacological and catheter-based treatment strategies show promise, but the data supporting their use in patients are sparse. We therefore aimed to develop an in vivo model of acute PE enabling controlled evaluations of efficacy and safety of novel therapies. Danish Landrace pigs (n = 8) were anaesthetized and mechanically ventilated. Two pre-formed autologous PEs (PE1, PE2, 20 × 1 cm) were administered consecutively via the right external jugular vein. The intact nature and central location were visualized in situ by magnetic resonance imaging (MRI). The hemodynamic and biochemical responses were evaluated at baseline (BL) and after each PE by invasive pressure measurements, MRI, plus arterial and venous blood analysis. Pulmonary arterial pressure increased after administration of the PEs (BL: 16.3 ± 1.2, PE1: 27.6 ± 2.9, PE2: 31.6 ± 3.1 mmHg, BL vs. PE1: P = 0.0027, PE1 vs. PE2: P = 0.22). Animals showed signs of right ventricular strain evident by increased end systolic volume (BL: 60.9 ± 5.1, PE1: 83.3 ± 5.0, PE2: 99.4 ± 6.5 mL, BL vs. PE1: P = 0.0005, PE1 vs. PE2: P = 0.0045) and increased plasma levels of Troponin T. Ejection fraction decreased (BL: 58.9 ± 2.4, PE1: 46.4 ± 2.9, PE2: 37.3 ± 3.5%, BL vs. PE1: p = 0.0008, PE1 vs. PE2: P = 0.009) with a compensatory increase in heart rate preserving cardiac output and systemic blood pressure. The hemodynamic and biochemical responses were comparable to that of patients suffering from intermediate-high-risk PE. This porcine model mirrors the anatomical and physiologic changes seen in human patients with intermediate-high-risk PE, and may enable testing of future therapies for this disease.
Collapse
Affiliation(s)
- Jacob Schultz
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Asger Andersen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Inger Lise Gade
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | | | - Benedict Kjaergaard
- Department of Thoracic Surgery, Aalborg University Hospital, Aalborg, Denmark
| | | |
Collapse
|
22
|
A retrospective comparison of survivors and non-survivors of massive pulmonary embolism receiving veno-arterial extracorporeal membrane oxygenation support. Resuscitation 2018; 122:1-5. [DOI: 10.1016/j.resuscitation.2017.11.034] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 10/13/2017] [Accepted: 11/03/2017] [Indexed: 12/15/2022]
|
23
|
Pang P, Lok C. Clinical Quiz: What Causes a Rapidly Fatal Event within Hours? HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490790000700310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Pkm Pang
- Yan Chai Hospital, Accident & Emergency Department, Tsuen Wan, N.T., Hong Kong
| | | |
Collapse
|
24
|
Abstract
Pulmonary embolism (PE) is a serious and prevalent cause of vascular disease. Nevertheless, optimal treatment for many phenotypes of PE remains uncertain. Treating PE requires appropriate risk stratification as a first step. For the highest-risk PE, presenting as shock or arrest, emergent systemic thrombolysis or embolectomy is reasonable, while for low-risk PE, anticoagulation alone is often chosen. Normotensive patients with PE but with indicia of right heart dysfunction (by biomarkers or imaging) constitute an intermediate-risk group for whom there is controversy on therapeutic strategy. Some intermediate-risk patients with PE may require urgent stabilization, and ≈10% will decompensate hemodynamically and suffer high mortality, though identifying these specific patients remains challenging. Systemic thrombolysis is a consideration, but its risks of major and intracranial hemorrhages rival overall harms from intermediate PE. Multiple hybrid pharmacomechanical approaches have been devised to capture the benefits of thrombolysis while reducing its risks, but there is limited aggregate clinical experience with such novel interventional strategies. One method to counteract uncertainty and generate a consensus multidisciplinary prognostic and therapeutic plan is through a Pulmonary Embolism Response Team, which combines expertise from interventional cardiology, interventional radiology, cardiac surgery, cardiac imaging, and critical care. Such a team can help determine which intervention-catheter-directed fibrinolysis, ultrasound-assisted thrombolysis, percutaneous mechanical thrombus fragmentation, or percutaneous or surgical embolectomy-is best suited to a particular patient. This article reviews these various modalities and the background for each.
Collapse
Affiliation(s)
- David M Dudzinski
- From the Cardiology Division (D.M.D., K.R.) and Vascular Medicine (K.R.), Massachusetts General Hospital, Boston; and Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia (J.G.).
| | - Jay Giri
- From the Cardiology Division (D.M.D., K.R.) and Vascular Medicine (K.R.), Massachusetts General Hospital, Boston; and Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia (J.G.)
| | - Kenneth Rosenfield
- From the Cardiology Division (D.M.D., K.R.) and Vascular Medicine (K.R.), Massachusetts General Hospital, Boston; and Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia (J.G.)
| |
Collapse
|
25
|
Rougé A, Perriollat L, Abdellaoui M, Faurie B, Monségu J. [Management of high-risk pulmonary embolism with pulmonary artery trunk mobile thrombus]. Ann Cardiol Angeiol (Paris) 2017; 66:346-349. [PMID: 29029777 DOI: 10.1016/j.ancard.2017.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 09/12/2017] [Indexed: 06/07/2023]
Abstract
The presence of a right intraventricular thrombus is a marker of severity of pulmonary embolism (PE), and is associated with high mortality. We report the case of a young patient with a PE postoperative of patellar tendon surgery. The cardiac echocardiography at its admission revealed a voluminous mobile thrombus of 1.7cm diameter located on the pulmonary trunk. Systemic thrombolysis was performed because of respiratory deterioration allowing a rapid disappearance of the thrombus and recovery. Our case emphasizes the value of a complete ultrasound analysis centered on the pulmonary trunk in the case of intermediate-risk PE. No recommendation exists on the management of these right ventricular thrombi, thrombolysis appearing to be the first-line treatment.
Collapse
Affiliation(s)
- A Rougé
- Institut cardiovasculaire, groupe hospitalier Mutualiste, 8, rue Dr-Calmette, 38000 Grenoble, France.
| | - L Perriollat
- Institut cardiovasculaire, groupe hospitalier Mutualiste, 8, rue Dr-Calmette, 38000 Grenoble, France.
| | - M Abdellaoui
- Institut cardiovasculaire, groupe hospitalier Mutualiste, 8, rue Dr-Calmette, 38000 Grenoble, France.
| | - B Faurie
- Institut cardiovasculaire, groupe hospitalier Mutualiste, 8, rue Dr-Calmette, 38000 Grenoble, France.
| | - J Monségu
- Institut cardiovasculaire, groupe hospitalier Mutualiste, 8, rue Dr-Calmette, 38000 Grenoble, France.
| |
Collapse
|
26
|
Kline JA, Hall CL, Jones AE, Puskarich MA, Mastouri RA, Lahm T. Randomized trial of inhaled nitric oxide to treat acute pulmonary embolism: The iNOPE trial. Am Heart J 2017; 186:100-110. [PMID: 28454823 PMCID: PMC5412723 DOI: 10.1016/j.ahj.2017.01.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 01/21/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND The study hypothesis is that administration of inhaled nitric oxide (NO) plus oxygen to subjects with submassive pulmonary embolism (PE) will improve right ventricular (RV) systolic function and reduce RV strain and necrosis, while improving patient dyspnea, more than treatment with oxygen alone. METHODS This article describes the rationale and protocol for a registered (NCT01939301), nearly completed phase II, 3-center, randomized, double-blind, controlled trial. Eligible patients have pulmonary imaging-proven acute PE. Subjects must be normotensive, and have RV dysfunction on echocardiography or elevated troponin or brain natriuretic peptide and no fibrinolytics. Subjects receive NO plus oxygen or placebo for 24 hours (±3 hours) with blood sampling before and after treatment, and mandatory echocardiography and high-sensitivity troponin posttreatment to assess the composite primary end point. The sample size of N=78 was predicated on 30% more NO-treated patients having a normal high-sensitivity troponin (<14 pg/mL) and a normal RV on echocardiography at 24 hours with α=.05 and β=.20. Safety was ensured by continuous spectrophotometric monitoring of percentage of methemoglobinemia and a predefined protocol to respond to emergent changes in condition. Blinding was ensured by identical tanks, software, and physical shielding of the device display and query of the clinical care team to assess blinding efficacy. RESULTS We have enrolled 78 patients over a 31-month period. No patient has been withdrawn as a result of a safety concern, and no patient has had a serious adverse event related to NO. CONCLUSIONS We present methods and a protocol for the first double-blinded, randomized trial of inhaled NO to treat PE.
Collapse
Affiliation(s)
- Jeffrey A Kline
- Indiana University School of Medicine, Department of Emergency Medicine, 720 Eskenazi Ave, Fifth Third Faculty Office Bldg, 3rd Floor Emergency Medicine Office, Indianapolis, IN.
| | - Cassandra L Hall
- Indiana University School of Medicine, Department of Emergency Medicine, 1701 N Senate Blvd, AG001, Indianapolis, IN.
| | - Alan E Jones
- Department of Emergency Medicine, University of Mississippi Medical Center, 2500 N State St, Jackson, MS.
| | - Michael A Puskarich
- Department of Emergency Medicine, University of Mississippi Medical Center, 2500 N State St, Jackson, MS.
| | - Ronald A Mastouri
- Indiana University School of Medicine, Department of Medicine, Division of Cardiology, Indianapolis, IN.
| | - Tim Lahm
- Division of Pulmonary, Allergy, Critical Care, Occupational and Sleep Medicine, Indiana University School of Medicine, Richard L. Roudebush VA Medical Center, Walther Hall, Room C400, 980 W Walnut St, Indianapolis, IN.
| |
Collapse
|
27
|
Bloomer TL, El-Hayek GE, McDaniel MC, Sandvall BC, Liberman HA, Devireddy CM, Kumar G, Fong PP, Jaber WA. Safety of catheter-directed thrombolysis for massive and submassive pulmonary embolism: Results of a multicenter registry and meta-analysis. Catheter Cardiovasc Interv 2017; 89:754-760. [PMID: 28145042 DOI: 10.1002/ccd.26900] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 12/11/2016] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To evaluate the safety and efficacy of catheter-directed thrombolysis (CDT) in the treatment of acute pulmonary embolism (PE). BACKGROUND The use of CDT for the treatment of acute submassive and massive PE is increasing in frequency. However, its safety and efficacy have not been well elucidated. METHODS This study is made of two parts: one is a two-center registry of acute PE patients treated with CDT. The safety outcome evaluated was any major complication including fatal, intracranial (ICH), intraocular, or retroperitoneal hemorrhage or any overt bleeding requiring transfusion or surgical repair. The efficacy outcome was acute change in invasive pulmonary artery systolic pressure (PASP). The second part is a meta-analysis of all contemporary studies that used CDT for PE. Reported outcomes are the same as in the registry, with the addition of right ventricular to left ventricular (RV/LV) ratio change. RESULTS In the registry, 137 patients were included (age 59 ± 15, 50% male, 88% submassive PE). ICH occurred in two patients and major complications in 13 (9.4%). PASP decreased post procedure by 19 ± 15 mm Hg (95% CI 16-23). In the meta-analysis, 16 studies were included with 860 patients. Rate of ICH was 0.35% and the major complication rate was 4.65%, most requiring transfusion only. In-hospital mortality was 12.9% in the massive and 0.74% in the submassive group. All studies showed improvement in PASP and/or RV/LV ratio post CDT. CONCLUSIONS CDT is associated with a low major complication rate. Randomized studies are needed to evaluate its efficacy relative to anticoagulation alone. © 2017 Wiley Periodicals, Inc.
Collapse
Affiliation(s)
- Tyler L Bloomer
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Georges E El-Hayek
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Michael C McDaniel
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Breck C Sandvall
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Henry A Liberman
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Chandan M Devireddy
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Gautam Kumar
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Pete P Fong
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Wissam A Jaber
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| |
Collapse
|
28
|
Thrombophilias and Acute Pulmonary Thromboembolic Disease. Respir Med 2017. [DOI: 10.1007/978-3-319-41912-1_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
29
|
Thrombolytic Therapy by Tissue Plasminogen Activator for Pulmonary Embolism. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2016; 906:67-74. [DOI: 10.1007/5584_2016_106] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
|
30
|
Liew A, Malley T. Tough decisions in pulmonary embolism: thrombolysis or embolectomy? Oxf Med Case Reports 2016; 2016:omw070. [PMID: 27617104 PMCID: PMC5015420 DOI: 10.1093/omcr/omw070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 07/11/2016] [Accepted: 07/17/2016] [Indexed: 11/23/2022] Open
|
31
|
Ozmen C, Deniz A, Akilli RE, Deveci OS, Cagliyan CE, Aktas H, Celik Aİ, Akpinar AA, Disel NR, Balli HT, Hanta İ, Demir M, Usal A, Kanadasi M. Ultrasound Accelerated Thrombolysis May Be an Effective and Safe Treatment Modality for Intermediate Risk/Submassive Pulmonary Embolism. Int Heart J 2015; 57:91-5. [PMID: 26673444 DOI: 10.1536/ihj.15-271] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Pulmonary embolism (PE) is a potentially life-threatening condition and the fact that 90% of PE originate from lower limb veins highlights the significance of early detection and treatment of deep vein thrombosis. Massive/high risk PE involving circulatory collapse or systemic arterial hypotension is associated with an early mortality rate of approximately 50%, in part from right ventricular (RV) failure. Intermediate risk/submassive PE, on the other hand, is defined as PE-related RV dysfunction, troponin and/or B-type natriuretic peptide elevation despite normal arterial pressure. Without prompt treatment, patients with intermediate risk PE may progress to the massive category with a potentially fatal outcome. In patients with PE and right ventricular dysfunction (RVD), in hospital mortality ranges from 5% to 17%, significantly higher than in patients without RVD.
Collapse
Affiliation(s)
- Caglar Ozmen
- Department of Cardiology, Cukurova University, Faculty of Medicine
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
32
|
Abstract
Pulmonary embolism can present with a wide range of symptoms, from asymptomatic to cardiac arrest, making diagnosis challenging. Alteplase is a fibrinolytic that is indicated for the treatment of pulmonary embolism in intermediate- and high-risk patients. Controversy exists as to the patient population that will benefit most from fibrinolytic therapy, as well as the proper dose and administration technique. The patient's risk of bleeding should be weighed against the potential benefits of treatment in light of the clinical presentation because of the high mortality rate associated with pulmonary embolism. Nurses at the bedside must monitor for signs of bleeding when alteplase is administered. Fibrinolytic therapy will frequently be started in the emergency department, and the nurse must ensure that alteplase is administered in a safe and effective manner. This review discusses the clinical evidence for alteplase in pulmonary embolism and its specific role in treatment.
Collapse
|
33
|
Abstract
BACKGROUND Thrombolytic therapy (powerful anticoagulation drugs) is usually reserved for patients with clinically serious or massive pulmonary embolism (PE). Evidence suggests that thrombolytic agents may dissolve blood clots more rapidly than heparin and reduce the death rate associated with PE. However, there are still concerns about the possible risk of adverse effects of thrombolytic therapy, such as major or minor haemorrhages. This is the second update of the Cochrane review first published in 2006. OBJECTIVES To assess the effects of thrombolytic therapy in patients with acute pulmonary embolism. SEARCH METHODS For this update the Cochrane Vascular Group searched their Specialised Register (last searched September 2014) and the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library (last searched Issue 8, 2014). We also searched individual trial collections and private databases, along with bibliographies of relevant articles. We handsearched relevant medical journals. SELECTION CRITERIA Randomised controlled trials (RCTs) that compared thrombolytic therapy followed by heparin versus heparin alone, heparin plus placebo or surgical intervention in patients with acute PE. We did not include trials comparing two different thrombolytic agents or different doses of the same thrombolytic drug. DATA COLLECTION AND ANALYSIS Two authors (BD and QH) assessed the eligibility and quality of trials and extracted data. MAIN RESULTS We identified 18 trials with a total of 2197 participants for inclusion in the review. We were not able to include one study in the meta-analysis because it had no data to extract. Most of the studies carried a high risk of bias because of high or unclear risk relating to randomisation and blinding. Meta-analysis showed that, compared with heparin alone, or heparin plus placebo, thrombolytics plus heparin can reduce the odds of death (odds ratio (OR) 0.57, 95% confidence interval (CI) 0.37 to 0.87, P = 0.02, low quality evidence) and recurrence of PE (OR 0.51; 95% CI 0.29 to 0.89, P = 0.02, low quality evidence). The effects of death weakened when we excluded four studies at high risk of bias from analysis: OR 0.66, 95% CI 0.42 to 1.06, P = 0.08. The incidence of major and minor haemorrhagic events was higher in the thrombolytics group than in the control group, and this difference was statistically significant (OR 2.90, 95% CI 1.95 to 4.31, P < 0.001, low quality evidence; OR 3.09, 95% CI 1.58 to 6.06, P = 0.001, very low quality evidence, respectively). Length of hospital stay (mean difference (MD) -1.35, 95% CI -4.27 to 1.58) and quality of life were similar between the two treatment groups. Stroke was reported in one study and occurred more often in the thrombolytics group than in the control group, although the confidence interval was wide (OR 12.10, 95% CI 1.57 to 93.39). Limited information from a small number of trials indicated that thrombolytics may improve haemodynamic outcomes, perfusion lung scanning, pulmonary angiogram assessment, echocardiograms, pulmonary hypertension, coagulation parameters, clinical outcomes and survival time to a greater extent than heparin alone. However, the heterogeneity of the studies and small number of participants involved warrant caution when interpreting results. Similarily, fewer patients from the thrombolytics group required escalation of treatment. None of the included studies reported on post-thrombotic syndrome or compared the cost of the different treatments. AUTHORS' CONCLUSIONS There is low quality evidence that thrombolytics reduce death following acute pulmonary embolism compared with heparin. Furthermore, thrombolytic therapies included in the review were heterogeneous. Thrombolytic therapy may be helpful in reducing the recurrence of pulmonary emboli but may cause more major and minor haemorrhagic events and stroke. More high quality double blind RCTs assessing safety and cost-effectiveness are required.
Collapse
Affiliation(s)
- Qiukui Hao
- Center of Geriatrics and Gerontology, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, Sichuan, China, 610041
| | | | | | | | | |
Collapse
|
34
|
Abstract
Pulmonary embolism (PE) is a common diagnosis in critical care. Depending on the severity of clot burden, the clinical picture ranges from nearly asymptomatic to cardiovascular collapse. The signs and symptoms of PE are nonspecific. The clinician must have a high index of suspicion to make the diagnosis. PE is risk stratified into 3 categories: low-risk, submassive, and massive. Submassive PE remains the most challenging with regard to initial and long-term management. Little consensus exists as to the appropriate tests for risk stratification and therapy. This article reviews the current literature and a suggested approach to these patients.
Collapse
Affiliation(s)
- Laurence W Busse
- Section of Critical Care Medicine, Department of Medicine, Inova Fairfax Medical Center, 3300 Gallows Road, Falls Church, VA 22042, USA.
| | - Jason S Vourlekis
- Section of Critical Care Medicine, Department of Medicine, Inova Fairfax Medical Center, 3300 Gallows Road, Falls Church, VA 22042, USA
| |
Collapse
|
35
|
Patel N, Patel NJ, Agnihotri K, Panaich SS, Thakkar B, Patel A, Savani C, Patel N, Arora S, Deshmukh A, Bhatt P, Alfonso C, Cohen M, Tafur A, Elder M, Mohamed T, Attaran R, Schreiber T, Grines C, Badheka AO. Utilization of catheter-directed thrombolysis in pulmonary embolism and outcome difference between systemic thrombolysis and catheter-directed thrombolysis. Catheter Cardiovasc Interv 2015; 86:1219-27. [DOI: 10.1002/ccd.26108] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Accepted: 06/20/2015] [Indexed: 12/29/2022]
Affiliation(s)
- Nish Patel
- Cardiology Department; University of Miami Miller School of Medicine; Miami Florida
| | - Nileshkumar J. Patel
- Internal Medicine Department; Staten Island University Hospital; Staten Island New York
| | - Kanishk Agnihotri
- Internal Medicine Department; Saint Peters University Hospital; New Brunswick New Jersey
| | | | - Badal Thakkar
- Internal Medicine Department; Tulane School of Public Health and Tropical Medicine; New Orleans Louisiana
| | - Achint Patel
- Internal Medicine Department; Icahn School of Medicine at Mount Sinai; New York New York
| | - Chirag Savani
- Internal Medicine Department; New York Medical College; Valhalla New York
| | - Nilay Patel
- Internal Medicine Department; Saint Peters University Hospital; New Brunswick New Jersey
| | - Shilpkumar Arora
- Internal Medicine Department; Mount Sinai St Luke's Roosevelt Hospital; New York New York
| | | | - Parth Bhatt
- Internal Medicine Department; Tulane School of Public Health and Tropical Medicine; New Orleans Louisiana
| | - Carlos Alfonso
- Cardiology Department; University of Miami Miller School of Medicine; Miami Florida
| | - Mauricio Cohen
- Cardiology Department; University of Miami Miller School of Medicine; Miami Florida
| | - Alfonso Tafur
- Cardiology Department; North Shore University Health System; Chicago Illinois
| | - Mahir Elder
- Cardiology Department; Detroit Medical Center; Detroit Michigan
| | - Tamam Mohamed
- Cardiology Department; Detroit Medical Center; Detroit Michigan
| | - Ramak Attaran
- Cardiology Department; Yale School of Medicine; New Haven Connecticut
| | | | - Cindy Grines
- Cardiology Department; Detroit Medical Center; Detroit Michigan
| | - Apurva O. Badheka
- Cardiology Department; Yale School of Medicine; New Haven Connecticut
| |
Collapse
|
36
|
Bataillard A, Hebrard A, Gaide-Chevronnay L, Casez M, Dessertaine G, Durand M, Chavanon O, Albaladejo P. Extracorporeal life support for massive pulmonary embolism during pregnancy. Perfusion 2015; 31:169-71. [DOI: 10.1177/0267659115586578] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Massive pulmonary embolism is a leading cause of death during pregnancy. While the prevention of thromboembolic disease during the peripartum period is codified, there is no consensus regarding its treatment. We report two cases of pregnant women who had massive pulmonary embolisms (PE) and shock treated with veno-arterial extracorporeal life support (ECLS) and heparin therapy. Haemodynamic and oxygenation parameters were rapidly restored. The patients completely recovered and the pregnancies continued. The patients did not develop pulmonary hypertension. ECLS can be considered as a successful treatment option of massive pulmonary embolism during pregnancy.
Collapse
Affiliation(s)
- A Bataillard
- Grenoble University Hospital and University of Grenoble, Grenoble, France
| | - A Hebrard
- Grenoble University Hospital and University of Grenoble, Grenoble, France
| | - L Gaide-Chevronnay
- Grenoble University Hospital and University of Grenoble, Grenoble, France
| | - M Casez
- Grenoble University Hospital and University of Grenoble, Grenoble, France
| | - G Dessertaine
- Grenoble University Hospital and University of Grenoble, Grenoble, France
| | - M Durand
- Grenoble University Hospital and University of Grenoble, Grenoble, France
| | - O Chavanon
- Grenoble University Hospital and University of Grenoble, Grenoble, France
| | - P Albaladejo
- Grenoble University Hospital and University of Grenoble, Grenoble, France
| |
Collapse
|
37
|
Konstantinides SV, Wärntges S. Acute phase treatment of venous thromboembolism: advanced therapy. Systemic fibrinolysis and pharmacomechanical therapy. Thromb Haemost 2015; 113:1202-9. [PMID: 25789580 DOI: 10.1160/th14-11-0998] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2014] [Accepted: 02/01/2015] [Indexed: 11/05/2022]
Abstract
Venous thromboembolism, which encompasses deep-vein thrombosis and acute pulmonary embolism (PE), represents a major contributor to global disease burden worldwide. For patients who present with cardiogenic shock or persistent hypotension (acute high-risk PE), there is consensus that immediate reperfusion treatment applying systemic fibrinolysis or, in the case of a high bleeding risk, surgical or catheter-directed techniques, is indicated. On the other hand, for the large, heterogeneous group of patients presenting without overt haemodynamic instability, the indications for advanced therapy are less clear. The recently updated guidelines of the European Society of Cardiology emphasise the importance of clinical prediction rules in combination with imaging procedures (assessment of right ventricular function) and laboratory biomarkers (indicative of myocardial stress or injury) for distinguishing between an intermediate and a low risk for an adverse early outcome. In intermediate-high-risk PE defined by the presence of both right ventricular dysfunction on echocardiography (or computed tomography) and a positive troponin (or natriuretic peptide) test, the bleeding risks of full-dose fibrinolytic treatment have been shown to outweigh its potential clinical benefits unless clinical signs of haemodynamic decompensation appear (rescue fibrinolysis). Recently published trials suggest that catheter-directed, ultrasound-assisted, low-dose local fibrinolysis may provide an effective and particularly safe treatment option for some of these patients.
Collapse
Affiliation(s)
- Stavros V Konstantinides
- Stavros V. Konstantinides, MD, FESC, Center for Thrombosis and Haemostasis, University Medical Centre Mainz, Langenbeckstrasse 1, Bldg. 403, 55131 Mainz, Germany, Tel.: +49 6131 178382, Fax: +49 6131 173456, E-mail:
| | | |
Collapse
|
38
|
|
39
|
Pulmonary embolism in the pediatric emergency department: a case demonstrating the application of point-of-care cardiac ultrasound in a pediatric patient with pulmonary embolism. Pediatr Emerg Care 2014; 30:839-44. [PMID: 25373574 DOI: 10.1097/pec.0000000000000274] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Although pulmonary embolism in children is rare, it is important for the pediatric emergency medicine provider to be aware of its presentation and emergent management. We present a case of bilateral pulmonary embolisms in an adolescent patient to illustrate the benefits from the timely diagnosis of right ventricular dysfunction by point-of-care echocardiography performed by emergency medicine physicians. Ultrasonographic techniques and the emergent management of pulmonary embolism are reviewed.
Collapse
|
40
|
Konstantinides SV, Torbicki A, Agnelli G, Danchin N, Fitzmaurice D, Galiè N, Gibbs JSR, 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 embolism. Eur Heart J 2014; 35:3033-69, 3069a-3069k. [PMID: 25173341 DOI: 10.1093/eurheartj/ehu283] [Citation(s) in RCA: 1827] [Impact Index Per Article: 182.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
|
41
|
Engelhardt TC. Acute pulmonary embolus: the next frontier in venous thromboembolic interventions. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2014; 16:336. [PMID: 25074264 DOI: 10.1007/s11936-014-0336-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OPINION STATEMENT Submassive pulmonary embolism (PE) represents a patient population that is under-recognized and under-treated. Recent clinical trials demonstrated the hemodynamic benefit of IV thrombolytic therapy among these patients; however, it came at the cost of a significantly increased risk of major, particularly intracranial, hemorrhage. Catheter-based treatment modalities have garnered considerable clinical interest in recent years. In particular, ultrasound accelerated thrombolysis, a catheter-based technology that enhances the process of thrombolytic delivery into the thrombus, has emerged as a treatment modality with an increasing number of single-center studies, as well as randomized, controlled clinical trials. Results from these experiences are consistent in achieving outcomes of thrombus resolution and hemodynamic recovery with a low dose thrombolytic infusion protocol, but without the high risk of bleeding complications associated with IV thrombolysis. The clinical data will hopefully be impactful to the development of the next edition of the treatment guidelines, in support of overall recommendations for catheter-based interventions. When available and with appropriate expertise, this modality should be considered as the preferred treatment of both massive and submassive PE.
Collapse
Affiliation(s)
- Tod C Engelhardt
- Cardiovascular and Thoracic Surgery, Louisiana Heart, Lung and Vascular Institute, East Jefferson General Hospital, 4228 Houma Blvd Ste 300, Metairie, LA, 70006, USA,
| |
Collapse
|
42
|
Marti C, John G, Konstantinides S, Combescure C, Sanchez O, Lankeit M, Meyer G, Perrier A. Systemic thrombolytic therapy for acute pulmonary embolism: a systematic review and meta-analysis. Eur Heart J 2014; 36:605-14. [PMID: 24917641 PMCID: PMC4352209 DOI: 10.1093/eurheartj/ehu218] [Citation(s) in RCA: 301] [Impact Index Per Article: 30.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
AIM Thrombolytic therapy induces faster clot dissolution than anticoagulation in patients with acute pulmonary embolism (PE) but is associated with an increased risk of haemorrhage. We reviewed the risks and benefits of thrombolytic therapy in the management of patients with acute PE. METHODS AND RESULTS We systematically reviewed randomized controlled studies comparing systemic thrombolytic therapy plus anticoagulation with anticoagulation alone in patients with acute PE. Fifteen trials involving 2057 patients were included in our meta-analysis. Compared with heparin, thrombolytic therapy was associated with a significant reduction of overall mortality (OR; 0.59, 95% CI: 0.36-0.96). This reduction was not statistically significant after exclusion of studies including high-risk PE (OR; 0.64, 95% CI: 0.35-1.17). Thrombolytic therapy was associated with a significant reduction in the combined endpoint of death or treatment escalation (OR: 0.34, 95% CI: 0.22-0.53), PE-related mortality (OR: 0.29; 95% CI: 0.14-0.60) and PE recurrence (OR: 0.50; 95% CI: 0.27-0.94). Major haemorrhage (OR; 2.91, 95% CI: 1.95-4.36) and fatal or intracranial bleeding (OR: 3.18, 95% CI: 1.25-8.11) were significantly more frequent among patients receiving thrombolysis. CONCLUSIONS Thrombolytic therapy reduces total mortality, PE recurrence, and PE-related mortality in patients with acute PE. The decrease in overall mortality is, however, not significant in haemodynamically stable patients with acute PE. Thrombolytic therapy is associated with an increase of major and fatal or intracranial haemorrhage.
Collapse
Affiliation(s)
- Christophe Marti
- Department of Internal Medicine, Rehabilitation and Geriatrics, Geneva University Hospitals and Geneva Faculty of Medicine, Rue Gabrielle Perret-Gentil 4, 1211 Geneva 14, Switzerland
| | - Gregor John
- Department of Internal Medicine, Rehabilitation and Geriatrics, Geneva University Hospitals and Geneva Faculty of Medicine, Rue Gabrielle Perret-Gentil 4, 1211 Geneva 14, Switzerland
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis, University Medical Center Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - Christophe Combescure
- Department of Health and Community Medicine, University Hospitals of Geneva and Geneva Faculty of Medicine, Rue Gabrielle Perret-Gentil 4, 1211 Geneva 14, Switzerland
| | - Olivier Sanchez
- Hôpital Européen Georges Pompidou, AP-HP; Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S 970, Paris; GIRC Thrombose, France
| | - Mareike Lankeit
- Center for Thrombosis and Hemostasis, University Medical Center Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - Guy Meyer
- Hôpital Européen Georges Pompidou, AP-HP; Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S 970, Paris; GIRC Thrombose, France
| | - Arnaud Perrier
- Department of Internal Medicine, Rehabilitation and Geriatrics, Geneva University Hospitals and Geneva Faculty of Medicine, Rue Gabrielle Perret-Gentil 4, 1211 Geneva 14, Switzerland
| |
Collapse
|
43
|
Smithburger PL, Campbell S, Kane-Gill SL. Alteplase treatment of acute pulmonary embolism in the intensive care unit. Crit Care Nurse 2014; 33:17-27. [PMID: 23547122 DOI: 10.4037/ccn2013626] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Acute pulmonary embolism accounts for 50 000 to 100 000 deaths each year in the United States. Because of the wide spectrum of clinical manifestations, ranging from massive pulmonary embolism to small peripheral emboli, stratifying and treating patients according to their signs and symptoms is important when an acute embolism is suspected. Patients' clinical findings can range from no signs or symptoms to unstable hemodynamic status and shock. The 3-month mortality is 10% to 15%, but can be as high as 60% in patients with hemodynamic shock. This article reviews the classifications of acute peripheral emboli, explains the treatment of acute peripheral emboli, reviews the pharmacology of alteplase, and presents an assessment of the literature evaluating alteplase for the treatment of acute peripheral emboli. Clinical pearls for the administration, monitoring, and care of a patient receiving alteplase in an intensive care unit also are discussed.
Collapse
Affiliation(s)
- Pamela L Smithburger
- University of Pittsburgh School of Pharmacy, University of Pittsburgh Medical Center, 200 Lothrop St, Pittsburgh PA 15213, USA.
| | | | | |
Collapse
|
44
|
Kucher N, Boekstegers P, Müller OJ, Kupatt C, Beyer-Westendorf J, Heitzer T, Tebbe U, Horstkotte J, Müller R, Blessing E, Greif M, Lange P, Hoffmann RT, Werth S, Barmeyer A, Härtel D, Grünwald H, Empen K, Baumgartner I. Randomized, Controlled Trial of Ultrasound-Assisted Catheter-Directed Thrombolysis for Acute Intermediate-Risk Pulmonary Embolism. Circulation 2014; 129:479-86. [PMID: 24226805 DOI: 10.1161/circulationaha.113.005544] [Citation(s) in RCA: 636] [Impact Index Per Article: 63.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background—
In patients with acute pulmonary embolism, systemic thrombolysis improves right ventricular (RV) dilatation, is associated with major bleeding, and is withheld in many patients at risk. This multicenter randomized, controlled trial investigated whether ultrasound-assisted catheter-directed thrombolysis (USAT) is superior to anticoagulation alone in the reversal of RV dilatation in intermediate-risk patients.
Methods and Results—
Fifty-nine patients (63±14 years) with acute main or lower lobe pulmonary embolism and echocardiographic RV to left ventricular dimension (RV/LV) ratio ≥1.0 were randomized to receive unfractionated heparin and an USAT regimen of 10 to 20 mg recombinant tissue plasminogen activator over 15 hours (n=30; USAT group) or unfractionated heparin alone (n=29; heparin group). Primary outcome was the difference in the RV/LV ratio from baseline to 24 hours. Safety outcomes included death, major and minor bleeding, and recurrent venous thromboembolism at 90 days. In the USAT group, the mean RV/LV ratio was reduced from 1.28±0.19 at baseline to 0.99±0.17 at 24 hours (
P
<0.001); in the heparin group, mean RV/LV ratios were 1.20±0.14 and 1.17±0.20, respectively (
P
=0.31). The mean decrease in RV/LV ratio from baseline to 24 hours was 0.30±0.20 versus 0.03±0.16 (
P
<0.001), respectively. At 90 days, there was 1 death (in the heparin group), no major bleeding, 4 minor bleeding episodes (3 in the USAT group and 1 in the heparin group;
P
=0.61), and no recurrent venous thromboembolism.
Conclusions—
In patients with pulmonary embolism at intermediate risk, a standardized USAT regimen was superior to anticoagulation with heparin alone in reversing RV dilatation at 24 hours, without an increase in bleeding complications.
Clinical Trial Registration—
URL:
http://www.clinicaltrials.gov
. Unique identifier: NCT01166997.
Collapse
Affiliation(s)
- Nils Kucher
- From the Division of Vascular Medicine, Swiss Cardiovascular Center, University Hospital Bern, Bern, Switzerland (N.K., I.B.); Helios Hospital Siegburg, Siegburg, Germany (P.B., J.H., R.M.); Internal Medicine III, University Hospital Heidelberg, Heidelberg, Germany (O.J.M., E.B.); Großhadern Hospital, Ludwig-Maximilians University Munich, Munich, Germany (C.K., M.G., P.L.); University Hospital Carl Gustav Carus of Technical University Dresden, Dresden, Germany (J.B.-W., R.H., S.W.); Dortmund
| | - Peter Boekstegers
- From the Division of Vascular Medicine, Swiss Cardiovascular Center, University Hospital Bern, Bern, Switzerland (N.K., I.B.); Helios Hospital Siegburg, Siegburg, Germany (P.B., J.H., R.M.); Internal Medicine III, University Hospital Heidelberg, Heidelberg, Germany (O.J.M., E.B.); Großhadern Hospital, Ludwig-Maximilians University Munich, Munich, Germany (C.K., M.G., P.L.); University Hospital Carl Gustav Carus of Technical University Dresden, Dresden, Germany (J.B.-W., R.H., S.W.); Dortmund
| | - Oliver J. Müller
- From the Division of Vascular Medicine, Swiss Cardiovascular Center, University Hospital Bern, Bern, Switzerland (N.K., I.B.); Helios Hospital Siegburg, Siegburg, Germany (P.B., J.H., R.M.); Internal Medicine III, University Hospital Heidelberg, Heidelberg, Germany (O.J.M., E.B.); Großhadern Hospital, Ludwig-Maximilians University Munich, Munich, Germany (C.K., M.G., P.L.); University Hospital Carl Gustav Carus of Technical University Dresden, Dresden, Germany (J.B.-W., R.H., S.W.); Dortmund
| | - Christian Kupatt
- From the Division of Vascular Medicine, Swiss Cardiovascular Center, University Hospital Bern, Bern, Switzerland (N.K., I.B.); Helios Hospital Siegburg, Siegburg, Germany (P.B., J.H., R.M.); Internal Medicine III, University Hospital Heidelberg, Heidelberg, Germany (O.J.M., E.B.); Großhadern Hospital, Ludwig-Maximilians University Munich, Munich, Germany (C.K., M.G., P.L.); University Hospital Carl Gustav Carus of Technical University Dresden, Dresden, Germany (J.B.-W., R.H., S.W.); Dortmund
| | - Jan Beyer-Westendorf
- From the Division of Vascular Medicine, Swiss Cardiovascular Center, University Hospital Bern, Bern, Switzerland (N.K., I.B.); Helios Hospital Siegburg, Siegburg, Germany (P.B., J.H., R.M.); Internal Medicine III, University Hospital Heidelberg, Heidelberg, Germany (O.J.M., E.B.); Großhadern Hospital, Ludwig-Maximilians University Munich, Munich, Germany (C.K., M.G., P.L.); University Hospital Carl Gustav Carus of Technical University Dresden, Dresden, Germany (J.B.-W., R.H., S.W.); Dortmund
| | - Thomas Heitzer
- From the Division of Vascular Medicine, Swiss Cardiovascular Center, University Hospital Bern, Bern, Switzerland (N.K., I.B.); Helios Hospital Siegburg, Siegburg, Germany (P.B., J.H., R.M.); Internal Medicine III, University Hospital Heidelberg, Heidelberg, Germany (O.J.M., E.B.); Großhadern Hospital, Ludwig-Maximilians University Munich, Munich, Germany (C.K., M.G., P.L.); University Hospital Carl Gustav Carus of Technical University Dresden, Dresden, Germany (J.B.-W., R.H., S.W.); Dortmund
| | - Ulrich Tebbe
- From the Division of Vascular Medicine, Swiss Cardiovascular Center, University Hospital Bern, Bern, Switzerland (N.K., I.B.); Helios Hospital Siegburg, Siegburg, Germany (P.B., J.H., R.M.); Internal Medicine III, University Hospital Heidelberg, Heidelberg, Germany (O.J.M., E.B.); Großhadern Hospital, Ludwig-Maximilians University Munich, Munich, Germany (C.K., M.G., P.L.); University Hospital Carl Gustav Carus of Technical University Dresden, Dresden, Germany (J.B.-W., R.H., S.W.); Dortmund
| | - Jan Horstkotte
- From the Division of Vascular Medicine, Swiss Cardiovascular Center, University Hospital Bern, Bern, Switzerland (N.K., I.B.); Helios Hospital Siegburg, Siegburg, Germany (P.B., J.H., R.M.); Internal Medicine III, University Hospital Heidelberg, Heidelberg, Germany (O.J.M., E.B.); Großhadern Hospital, Ludwig-Maximilians University Munich, Munich, Germany (C.K., M.G., P.L.); University Hospital Carl Gustav Carus of Technical University Dresden, Dresden, Germany (J.B.-W., R.H., S.W.); Dortmund
| | - Ralf Müller
- From the Division of Vascular Medicine, Swiss Cardiovascular Center, University Hospital Bern, Bern, Switzerland (N.K., I.B.); Helios Hospital Siegburg, Siegburg, Germany (P.B., J.H., R.M.); Internal Medicine III, University Hospital Heidelberg, Heidelberg, Germany (O.J.M., E.B.); Großhadern Hospital, Ludwig-Maximilians University Munich, Munich, Germany (C.K., M.G., P.L.); University Hospital Carl Gustav Carus of Technical University Dresden, Dresden, Germany (J.B.-W., R.H., S.W.); Dortmund
| | - Erwin Blessing
- From the Division of Vascular Medicine, Swiss Cardiovascular Center, University Hospital Bern, Bern, Switzerland (N.K., I.B.); Helios Hospital Siegburg, Siegburg, Germany (P.B., J.H., R.M.); Internal Medicine III, University Hospital Heidelberg, Heidelberg, Germany (O.J.M., E.B.); Großhadern Hospital, Ludwig-Maximilians University Munich, Munich, Germany (C.K., M.G., P.L.); University Hospital Carl Gustav Carus of Technical University Dresden, Dresden, Germany (J.B.-W., R.H., S.W.); Dortmund
| | - Martin Greif
- From the Division of Vascular Medicine, Swiss Cardiovascular Center, University Hospital Bern, Bern, Switzerland (N.K., I.B.); Helios Hospital Siegburg, Siegburg, Germany (P.B., J.H., R.M.); Internal Medicine III, University Hospital Heidelberg, Heidelberg, Germany (O.J.M., E.B.); Großhadern Hospital, Ludwig-Maximilians University Munich, Munich, Germany (C.K., M.G., P.L.); University Hospital Carl Gustav Carus of Technical University Dresden, Dresden, Germany (J.B.-W., R.H., S.W.); Dortmund
| | - Philipp Lange
- From the Division of Vascular Medicine, Swiss Cardiovascular Center, University Hospital Bern, Bern, Switzerland (N.K., I.B.); Helios Hospital Siegburg, Siegburg, Germany (P.B., J.H., R.M.); Internal Medicine III, University Hospital Heidelberg, Heidelberg, Germany (O.J.M., E.B.); Großhadern Hospital, Ludwig-Maximilians University Munich, Munich, Germany (C.K., M.G., P.L.); University Hospital Carl Gustav Carus of Technical University Dresden, Dresden, Germany (J.B.-W., R.H., S.W.); Dortmund
| | - Ralf-Thorsten Hoffmann
- From the Division of Vascular Medicine, Swiss Cardiovascular Center, University Hospital Bern, Bern, Switzerland (N.K., I.B.); Helios Hospital Siegburg, Siegburg, Germany (P.B., J.H., R.M.); Internal Medicine III, University Hospital Heidelberg, Heidelberg, Germany (O.J.M., E.B.); Großhadern Hospital, Ludwig-Maximilians University Munich, Munich, Germany (C.K., M.G., P.L.); University Hospital Carl Gustav Carus of Technical University Dresden, Dresden, Germany (J.B.-W., R.H., S.W.); Dortmund
| | - Sebastian Werth
- From the Division of Vascular Medicine, Swiss Cardiovascular Center, University Hospital Bern, Bern, Switzerland (N.K., I.B.); Helios Hospital Siegburg, Siegburg, Germany (P.B., J.H., R.M.); Internal Medicine III, University Hospital Heidelberg, Heidelberg, Germany (O.J.M., E.B.); Großhadern Hospital, Ludwig-Maximilians University Munich, Munich, Germany (C.K., M.G., P.L.); University Hospital Carl Gustav Carus of Technical University Dresden, Dresden, Germany (J.B.-W., R.H., S.W.); Dortmund
| | - Achim Barmeyer
- From the Division of Vascular Medicine, Swiss Cardiovascular Center, University Hospital Bern, Bern, Switzerland (N.K., I.B.); Helios Hospital Siegburg, Siegburg, Germany (P.B., J.H., R.M.); Internal Medicine III, University Hospital Heidelberg, Heidelberg, Germany (O.J.M., E.B.); Großhadern Hospital, Ludwig-Maximilians University Munich, Munich, Germany (C.K., M.G., P.L.); University Hospital Carl Gustav Carus of Technical University Dresden, Dresden, Germany (J.B.-W., R.H., S.W.); Dortmund
| | - Dirk Härtel
- From the Division of Vascular Medicine, Swiss Cardiovascular Center, University Hospital Bern, Bern, Switzerland (N.K., I.B.); Helios Hospital Siegburg, Siegburg, Germany (P.B., J.H., R.M.); Internal Medicine III, University Hospital Heidelberg, Heidelberg, Germany (O.J.M., E.B.); Großhadern Hospital, Ludwig-Maximilians University Munich, Munich, Germany (C.K., M.G., P.L.); University Hospital Carl Gustav Carus of Technical University Dresden, Dresden, Germany (J.B.-W., R.H., S.W.); Dortmund
| | - Henriette Grünwald
- From the Division of Vascular Medicine, Swiss Cardiovascular Center, University Hospital Bern, Bern, Switzerland (N.K., I.B.); Helios Hospital Siegburg, Siegburg, Germany (P.B., J.H., R.M.); Internal Medicine III, University Hospital Heidelberg, Heidelberg, Germany (O.J.M., E.B.); Großhadern Hospital, Ludwig-Maximilians University Munich, Munich, Germany (C.K., M.G., P.L.); University Hospital Carl Gustav Carus of Technical University Dresden, Dresden, Germany (J.B.-W., R.H., S.W.); Dortmund
| | - Klaus Empen
- From the Division of Vascular Medicine, Swiss Cardiovascular Center, University Hospital Bern, Bern, Switzerland (N.K., I.B.); Helios Hospital Siegburg, Siegburg, Germany (P.B., J.H., R.M.); Internal Medicine III, University Hospital Heidelberg, Heidelberg, Germany (O.J.M., E.B.); Großhadern Hospital, Ludwig-Maximilians University Munich, Munich, Germany (C.K., M.G., P.L.); University Hospital Carl Gustav Carus of Technical University Dresden, Dresden, Germany (J.B.-W., R.H., S.W.); Dortmund
| | - Iris Baumgartner
- From the Division of Vascular Medicine, Swiss Cardiovascular Center, University Hospital Bern, Bern, Switzerland (N.K., I.B.); Helios Hospital Siegburg, Siegburg, Germany (P.B., J.H., R.M.); Internal Medicine III, University Hospital Heidelberg, Heidelberg, Germany (O.J.M., E.B.); Großhadern Hospital, Ludwig-Maximilians University Munich, Munich, Germany (C.K., M.G., P.L.); University Hospital Carl Gustav Carus of Technical University Dresden, Dresden, Germany (J.B.-W., R.H., S.W.); Dortmund
| |
Collapse
|
45
|
Mookadam F, Mookadam M, Jiamsripong P, Goel R. Pulmonary thromboembolic disease spectrum: diagnostic and therapeutic strategies. Expert Rev Cardiovasc Ther 2014; 7:1421-8. [DOI: 10.1586/erc.09.118] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
46
|
|
47
|
Abstract
The relative hypercoagulable state of pregnancy leads to an increased risk of thrombotic complications, of which some may be life-threatening or medically devastating. In the non-pregnant patient, the current guidelines suggest thrombolysis as the primary treatment in acute ischemic stroke, myocardial infarction when percutaneous intervention is unavailable, certain cases of mechanical valve thrombosis, and pulmonary embolism with hemodynamic compromise or shock. Given that clinical trial data regarding thrombolytic use in pregnant women are absent due to exclusion, the goal of this review is to summarize the available published data regarding the use of thrombolytic agents and subsequent outcomes and complications in pregnant women. Overall, the use of thrombolytic agents in pregnancy is associated with a relatively low reported complication rate, especially given the severe medical conditions for which they are indicated. The data would suggest that thrombolysis should be considered for appropriate indications similar to that of non-pregnant patients. However, caution should be exercised when drawing conclusions regarding maternal and fetal safety, given the lack of controlled clinical trials including pregnant women and the nature of the weak evidence level of the cumulative data presented in this review.
Collapse
Affiliation(s)
- Eric J Gartman
- Pulmonary, Critical Care, and Sleep Medicine, Warren Alpert Medical School of Brown University, Memorial Hospital of Rhode Island, Pawtucket, RI, USA
| |
Collapse
|
48
|
Bilello KL, Murin S. Counterpoint: should systemic lytic therapy be used for submassive pulmonary embolism? No. Chest 2013; 143:299-302. [PMID: 23381310 DOI: 10.1378/chest.12-2449] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Kathryn L Bilello
- Department of Medicine, University of California San Francisco-Fresno Program, Fresno, CA
| | - Susan Murin
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California, Davis, School of Medicine, Sacramento, CA; Veterans Affairs Northern California Health Care System, Sacramento, CA.
| |
Collapse
|
49
|
Lankeit M, Konstantinides S. Thrombolytic therapy for submassive pulmonary embolism. Best Pract Res Clin Haematol 2012; 25:379-89. [DOI: 10.1016/j.beha.2012.06.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
|
50
|
Wong P, Baglin T. Epidemiology, risk factors and sequelae of venous thromboembolism. Phlebology 2012; 27 Suppl 2:2-11. [PMID: 22457300 DOI: 10.1258/phleb.2012.012s31] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The aim of this review was to discuss the epidemiology, risk factors and sequelae of venous thromboembolism (VTE). VTE has an incidence of 1-2 per 1000 people annually. The risk of VTE increases with age and is highest in Caucasians and African Americans. Combined oral contraceptives (COC), especially the third-generation COCs, have been strongly implicated in VTE. Hospitalized patients, especially patients with underlying malignancy and undergoing surgery, have a host of risk factors for VTE. Thrombophilia can predispose an individual to VTE but indiscriminate testing for thrombophilia in patients presenting with VTE is not indicated. VTE can have serious chronic sequelae in the form of post-thrombotic syndrome (PTS) and chronic thromboembolic pulmonary hypertension (CTPH). The risk of PTS and CTPH is increased with recurrent deep vein thrombosis and pulmonary embolism, respectively. Mortality from VTE can be as high as 21.6% at one year. Patients who had an episode of VTE have a high risk of subsequent VTE and this risk is highest in patients who had a first VTE event associated with malignancy. A good understanding of the epidemiology and risk factors of VTE will enable the treating medical practitioners to identify patients at risk and administer appropriate VTE prophylaxis to prevent the long-term consequences of VTE.
Collapse
Affiliation(s)
- P Wong
- Department of Vascular Surgery, Freeman Hospital, High Heaton, Newcastle-upon-Tyne, UK.
| | | |
Collapse
|