Systemic thrombolysis in haemodynamically unstable pulmonary embolism: The earlier the better?

Abstract

IntroductionThe temporal window for the administration of systemic thrombolysis (ST) in acute pulmonary embolism (PE) has not yet been clarified. We assessed the relationship between short-term cardiovascular (CV) mortality and time of ST administration. Material and methodsAmong 394 consecutive patients admitted between January 2010 and June 2017 with a confirmed PE, we retrospectively review the clinical and instrumental data of those labelled as high-risk PE (n = 76, 41 males, mean aged 64.7 ± 9.1 years old). ResultsA receiving operating curve (ROC) analysis established the optimal temporal threshold for the administration of the ST, in respect to the 30-day CV mortality at 8.5 h from the symptom onset (Area under Curve 0.79 ± 0.6, 95% CI 0.73–0.86, p < 0.0001). Mantel-Cox analysis showed that there was a significant difference in the distribution of survival between patients treated within 8.5 h from the beginning of symptoms onset to those treated after 8.6 h [log rank (Mantel-Cox) chi-square 9.68 p = 0.002]. Cox-regression analysis demonstrated that the administration of ST after 8.6 h from the symptom's onset was an independent predictor of 30-day CV mortality in high-risk PE patients (HR 7.81, 95% CI 1.84–33.05, p = 0.005), independently from the occurrence of major bleeding events (HR 5.89, 95% CI 1.38–25.13, p = 0.01), previous CAD (HR 3.31, 95& CI 1.07–10.231. p = 0.03), RV/LV ratio after 2 h from the administration ST > 1 (HR (12.91, 95% CI 3.04–54.77, p = 0.001) and PAH at discharge (HR 3.86, 95% CI 2.22–4.68, p = 0.002). ConclusionsST administered within 8.5 h from symptoms onset may be associated with a reduced 30-day CV mortality in high-risk PE patients.