Abstract
ResumoO tromboembolismo pulmonar permanece como um grande desafio terapêutico para os médicos especialistas, pois, apesar de todo investimento e desenvolvimento em seu diagnóstico, profilaxia e tratamento, essa condição continua sendo a principal causa de morte evitável em ambiente hospitalar. Ainda restam muitas dúvidas em relação a qual perfil de paciente vai se beneficiar de fato da terapia fibrinolítica sistêmica, sem ficar exposto a um grande risco de sangramento. A estratificação de risco e a avaliação do prognóstico do evento, através de escores clínicos de insuficiência ventricular direita, marcadores de dilatação e disfunção do ventrículo direito e avaliação da massa trombótica, associados ou de forma isolada, são ferramentas que podem auxiliar na identificação do paciente que irá se beneficiar dessa terapia. Os únicos consensos em relação à terapia fibrinolítica no tratamento do tromboembolismo pulmonar são: não deve ser indicada de forma rotineira; nenhum dos escores ou marcadores, isoladamente, devem justificar seu uso; e os pacientes com instabilidade hemodinâmica são os mais beneficiados. Além disto, deve-se avaliar cada caso em relação ao risco de sangramento, especialmente no sistema nervoso central.
Highlights
The first published reports of thrombolysin for fibrinolytic treatment of pulmonary thromboembolism (PTE) were based on studies with 43 patients (30 normotensive) undertaken between 1958 and 1964 at the Sloan Kettering Institute in New York and reported results that were neither cause for enthusiasm nor for concern.[1]
It can reveal abnormalities such as a new right branch blockage, elevation or depression of the right ventricular failure (RV) Dysfunction a) Cardiac troponin T (TT): this is a marker of myocardial injury which in normotensive PTE is associated with greater mortality (RR: 5.9), but it should not be used as the only parameter
Based on the data described, Systemic fibrinolytic therapy (SFT) is recommended in submassive PTE for patients at low risk of bleeding who show signs of clinical deterioration.[21,40]
Summary
Risk of death, recurrence of PTE, and development of chronic PH are more frequent among patients with acute RV failure (submassive PTE);[8] in view of this, for many years there has been debate on expanding use of SFT in these patients, since they are much more common than cases with HI.[9] published studies in which use of heparin has been compared with SFT for submassive PTE have not reported significant reductions in mortality with SFT and, because of this, its use has become established as restricted to just the 3 to 5% of patients with PTE who have HI.[8] Those who advocate using SFT in submassive PTE argue that the populations evaluated in clinical trials are subject to bias, such as, for example, in the Management Strategies and Prognosis of Pulmonary Embolism-3 (MAPPET 3) study, in which only 31%. The discussion is based on the results of a bibliographic review of articles listed on PubMed that were published in English during the last 10 years
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