Thrombolysis in PE

Today we discussed a patient who presented with a pulmonary embolism. Indications/Evidence for thrombolysis was discussed.

To Summarize:

In 2002, a paper in NEJM compared Aleplase and Heparin vs Heparin alone and demonstrated that patients in the alteplase arm had improved clinical courses. All patients had submassive PE (and evidence of RV dysfunction or Pulmonary HTN) without arterial hypotension. This was driven by escalation of therapy in the placebo arm, not death.

A 2004 metanalysis demonstrated thrombolytic therapy compared with heparin was associated with a significant reduction in recurrent pulmonary embolism or death (9.4% versus 19.0%) in studies that enrolled patients with hemodynamically unstable PEs.

Two pro and con commentaries were published in Archives of Internal Medicine in 2005 and are good reads.

Finally, a recent NEJM review can be found here.

Overall, this is an area with uncertaintly and more RCT evidence is needed.