To Thrombolyse or Not to Thrombolyse: Two Years Experience of Thrombolysis of Sub-Massive Pulmonary Embolism in a District General Hospital.

Muhammad Jawad,Caroline Apsey

doi:10.7759/cureus.11359

Abstract

AimsCurrent British Thoracic Society (BTS) guidelines only recommend thrombolysis of pulmonary embolism (PE) in patients who are haemodynamically compromised. Newer evidence suggests a mortality benefit for the thrombolysis of sub-massive PE with right ventricular strain. We wanted to assess the outcome and safety of thrombolysis in patients with sub-massive PE in a DGH.MethodsThe notes for patients with sub-massive PE and thrombolysis from a two-year period were reviewed. Evidence of right ventricular strain and myocardial necrosis based on bedside echocardiography, computed tomography (CT) scan and troponin T were indications for thrombolysis.ResultsA total of 22 patients had thrombolysis of PE in the study period (56±14 years). Fourteen patients were classified as sub-massive PE (55±15 years). Out of eight patients who had thrombolysis of massive PE (58±14 years), three were initially classified as sub-massive PE but deteriorated within the next 48 hours and became haemodynamically unstable. In all patients, the diagnosis was confirmed with a CT pulmonary angiography (CTPA).Mean troponin was 82 in the sub-massive PE group and 102 in the massive PE group. The clinical condition and haemodynamic of patients improved rapidly within a few hours after thrombolysis.Post-thrombolysis echocardiography was performed, 17 patients had normal right ventricles with normal pulmonary arterial pressures.ConclusionThrombolysis of sub-massive pulmonary embolism is feasible in a district general hospital and seems to be a safe procedure, particularly in younger patients. It results in rapid improvement in the clinical condition of patients with a small incidence of bleeding complications.

Highlights

Pulmonary embolism (PE) is a common condition managed in district general hospitals with an annual incidence in the UK between 60-70/100,000 [1]
The diagnosis was confirmed with a computed tomography (CT) pulmonary angiography (CTPA)
Grifoni et al show that 30% of patients with sub-massive PE showed signs of right ventricular dysfunction and out of these patients, 10% progressed to shock with a 5% mortality rate [3]

Summary

Introduction

Pulmonary embolism (PE) is a common condition managed in district general hospitals with an annual incidence in the UK between 60-70/100,000 [1]. Pulmonary embolism is associated with increased mortality rates for up to three months after the index PE event [2]. Treatment varies depending on the severity of the presentation, with current British Thoracic Society (BTS) guidelines only recommending thrombolysis of PE in patients who are haemodynamically compromised (massive PE). In patients with normal blood pressure and no signs of shock on presentation, RV dysfunction provides indirect evidence of severe pulmonary arterial obstruction and impending haemodynamic failure [3]. Acute right ventricular pressure overload at diagnosis is an important determinant of the severity and early clinical outcome of pulmonary embolism [4]

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