Abstract
A pulmonary embolism (PE) is an acute life-threatening respiratory event that results in upwards of 200,000 deaths per year in the United States. While anticoagulation is currently the standard of treatment for PEs, there is increasing evidence to suggest that in certain cases anticoagulation in combination with thrombolytic therapy may improve patient outcomes and reduce mortality. This article aims to compare the effects of combined intervention with thrombolytic therapy and anticoagulation to the effects of anticoagulation alone in patients with submassive PEs in terms of various outcome measures, including but not limited to: mortality, hemodynamic status, length of hospital stay, and safety. The methodology consisted of the critical appraisal of the primary literature articles pertaining to intervention with thrombolytic agents in cases of a submassive or intermediate risk PE, including a discussion of each study’s strengths and limitations. Ultimately, this review found that the use of thrombolytic agents in conjunction with anticoagulants has been associated with decreased hemodynamic decompensation and decreased length of hospital stay, with no change in mortality outcomes, at a cost of increased rate of bleeding and stroke. The use of thrombolytic agents with anticoagulants may be warranted in a specific subset of patients, but clinicians should consider the potential benefits and harms of this intervention.
Highlights
BackgroundIn the United States, roughly 600,000 pulmonary embolisms (PEs) occur yearly and result in upwards of 200,000 deaths per year
This study demonstrates that while the use of thrombolytics combined with heparin is not superior over heparin alone in reducing mortality following a submassive PE, thrombolytics plus heparin are superior in preventing the need for escalation of treatment including the need for secondary thrombolysis
This review aimed to assess the different outcomes associated with the use of thrombolytic therapy for the treatment of a submassive pulmonary embolism
Summary
In the United States, roughly 600,000 pulmonary embolisms (PEs) occur yearly and result in upwards of 200,000 deaths per year. To address long-term outcomes of systemic thrombolysis in intermediate-risk PE patients, a study by Konstantinides et al, in 2017, followed 709 of 1005 patients from the PEITHO trial above, for a two-year follow-up period This was a double-blind randomized controlled trial looking at adult patients with confirmed PE with right ventricular dysfunction on echocardiogram and/or computed tomography scan along with myocardial injury as evidenced by an elevated troponin level. Important secondary outcomes included recurrent PE within seven days, mean hospital stay, improvement in right ventricular function and death within 30 days Both groups received the same dose of unfractionated heparin. This study showed that there was a benefit to using a combination of tenecteplase with heparin as opposed to heparin alone in submassive pulmonary embolisms in order to improve right ventricular function, decrease length of hospital stay, and decrease rates of hemodynamic decompensation. The major strengths of this study include the stratification used to create equal groups, the study was limited by a very small sample size in a single center
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