Thrombolytic Therapy For Pulmonary Embolism Research Articles

P109 * Predictive role of erectile dysfunction in the development of coronary heart disease in patients with obstructive sleep apnea syndrome

P109 * Predictive role of erectile dysfunction in the development of coronary heart disease in patients with obstructive sleep apnea syndrome

Intracerebral Hemorrhage with Thrombolytic Therapy for Acute Pulmonary Embolism

Background Intracranial hemorrhage is one of the dreaded complications of thrombolytic therapy for acute pulmonary embolism. We identified patients with pulmonary embolism who may be at relatively high risk of intracerebral hemorrhage from those selected for thrombolytic therapy by their physicians and presumably thought to be of reasonable risk. Methods The number of patients discharged from short-stay hospitals in the United States from 1998 to 2008 with pulmonary embolism who received thrombolytic therapy and the proportion with intracerebral hemorrhage were determined from the Nationwide Inpatient Sample, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. Results From 1998 to 2008, 2,237,600 patients were discharged with a diagnosis of pulmonary embolism. Among patients who received thrombolytic therapy for pulmonary embolism, the prevalence of intracerebral hemorrhage was 430 of 49,500 (0.9%). The prevalence increased linearly with age more than 10 years. Intracerebral hemorrhage was less frequent in those with a primary diagnosis of pulmonary embolism (250/39,300 [0.6%]) than in those with a secondary diagnosis (180/10,300 [1.7%], P <. 0001). The prevalence of intracerebral hemorrhage was lower in patients aged 65 years or less with no kidney disease (90/16,900 [0.5%]) than in patients aged more than 65 years or with kidney disease (290/20,900 [1.4%], P <. 0001). The prevalence remained lower in those with a primary diagnosis (90/23,000 [0.4%] than in those with a secondary diagnosis (50/5700 [0.9%], P <. 0001). Conclusion The cause of intracerebral hemorrhage in patients with pulmonary embolism who receive thrombolytic therapy seems to be multifactorial and related to comorbidity and age.

Predictors of In-Hospital Mortality in Patients Receiving Thrombolytic Therapy for Pulmonary Embolism

Predictors of in-hospital mortality from massive pulmonary embolism (PE) were retrospectively assessed in 78 patients who received thrombolytic therapy. Mortality from PE was 19% (15 of 78). Mortality from PE was higher in those with shock, 36% (12 of 33) versus no shock, 7% (3 of 45; P = .001), 21% (7 of 34) with right ventricle (RV) hypokinesis, and 20% (13 of 64) with RV enlargement. Mortality was 14% (2 of 14) with normal cardiac troponin I (cTnI), 19% (4 of 21) with intermediate cTnI, and 22% (8 of 36) with high cTnI (comparisons between groups nonsignificant [NS]). Trends with combinations of risk factors showed the highest mortality with shock plus high cTnI plus RV hypokinesis (57%) or shock plus high cTnI plus RV enlargement (54%). In conclusion, among the single risk factors, shock was associated with the highest in-hospital mortality from PE and combinations with high cTnI and RV enlargement were associated with higher mortalities.

Forearm Compartment Syndrome following Thrombolytic Therapy for Massive Pulmonary Embolism: A Case Report and Review of Literature

Use of thrombolytic therapy in pulmonary embolism is restricted in cases of massive embolism. It achieves faster lysis of the thrombus than the conventional heparin therapy thus reducing the morbidity and mortality associated with PE. The compartment syndrome is a well-documented, potentially lethal complication of thrombolytic therapy and known to occur in the limbs involved for vascular lines or venepunctures. The compartment syndrome in a conscious and well-oriented patient is mainly diagnosed on clinical ground with its classical signs and symptoms like disproportionate pain, tense swollen limb and pain on passive stretch. However these findings may not be appropriately assessed in an unconscious patient and therefore the clinicians should have high index of suspicion in a patient with an acutely swollen tense limb. In such scenarios a prompt orthopaedic opinion should be considered. In this report, we present a case of acute compartment syndrome of the right forearm in a 78 years old male patient following repeated attempts to secure an arterial line for initiating the thrombolytic therapy for the management of massive pulmonary embolism. The patient underwent urgent surgical decompression of the forearm compartments and thus managed to save his limb.

Transfemoral Catheter Thrombolysis and Use of Sildenafil in Acute Massive Pulmonary Embolism

ACUTE PULMONARY EMBOLISM (PE) develops in approximately 630,000 people annually and contributes to 200,000 deaths annually. 1 Dalen J.E. Alpert J.S. Natural history of pulmonary embolism. Prog Cardiovasc Dis. 1975; 17: 259-270 Abstract Full Text PDF PubMed Scopus (955) Google Scholar The prophylactic use of heparin, vitamin K antagonists, or compression stockings are standard care in hospitalized individuals and particularly important in surgical patients because they have an increased risk for deep venous thrombosis and pulmonary embolism. The mortality associated with massive PE is secondary to acute right-heart failure and circulatory shock. 2 Lualdi J.C. Goldhaber S.Z. Right ventricular dysfunction after acute pulmonary embolism: Pathophysiologic factors, detection, and therapeutic implications. Am Heart J. 1995; 130: 1276-1282 Abstract Full Text PDF PubMed Scopus (263) Google Scholar Estimated mortality in the post-thrombolytic era in patients with acute PE with hemodynamic instability is between 23% and 38% 3 Arcasoy S.M. Kreit J.W. Thrombolytic therapy of pulmonary embolism: A comprehensive review of current evidence. Chest. 1999; 115: 1695-1707 Crossref PubMed Scopus (218) Google Scholar , 4 Dalen J.E. Alpert J.S. Hirsh J. Thrombolytic therapy for pulmonary embolism: Is it effective? Is it safe? When is it indicated?. Arch Intern Med. 1997; 157: 2550-2556 Crossref PubMed Google Scholar ; approximately 90% of these deaths occur within 2 hours of the onset of symptoms. 5 Soloff L.A. Rodman T. Acute pulmonary embolism II. Clinical. Am Heart J. 1967; 74: 829-847 Abstract Full Text PDF PubMed Scopus (70) Google Scholar , 6 Soloff L.A. Rodman T. Acute pulmonary embolism I. Review. Am Heart J. 1967; 74: 710-724 Abstract Full Text PDF PubMed Scopus (32) Google Scholar , 7 Stein P.D. Henry J.W. Prevalence of acute pulmonary embolism among patients in a general hospital and at autopsy. Chest. 1995; 108: 978-981 Crossref PubMed Scopus (609) Google Scholar , 8 Tapson V.F. Witty L.A. Massive pulmonary embolism Diagnostic and therapeutic strategies. Clin Chest Med. 1995; 16: 329-340 PubMed Google Scholar Acute right-heart failure together with poor filling of the left heart are indicative; this condition may rapidly lead to circulatory arrest. 2 Lualdi J.C. Goldhaber S.Z. Right ventricular dysfunction after acute pulmonary embolism: Pathophysiologic factors, detection, and therapeutic implications. Am Heart J. 1995; 130: 1276-1282 Abstract Full Text PDF PubMed Scopus (263) Google Scholar

Identification of Unexpected Nonatherosclerotic Cardiovascular Disease With Coronary CT Angiography

The aim of this study was to assess, in a general cardiology cohort screened for obstructive coronary artery disease (CAD), the effectiveness and frequency with which multidetector computed tomography (MDCT) angiography unexpectedly imaged and identified other nonatherosclerotic cardiovascular diseases. MDCT angiography is a novel imaging strategy employed primarily to diagnose CAD that, in the course of these studies, can also potentially identify other important but previously unrecognized cardiovascular abnormalities. Consecutive 64-slice MDCT angiography studies were obtained in 4,543 patients with suspected atherosclerotic CAD at the Minneapolis Heart Institute, over a 29-month period (2005 to 2007). Nonatherosclerotic-related cardiovascular abnormalities judged to be of potential clinical relevance were identified in 201 patients (4.4%). In 50 of these patients (1.1% of 4,543) the abnormality was previously unrecognized despite other imaging studies performed in 40%. Most common among the 50 patients were: congenital coronary artery anomalies (38%; largely right coronary artery from the left aortic sinus); ascending aortic aneurysms > or = 45 mm (22%); hypertrophic cardiomyopathy with apical left ventricular (LV) wall thickening (14%); valvular heart diseases (8%), congenital heart diseases, including ventricular septal defect (6%); pulmonary embolus (6%); as well as LV noncompaction, left atrial myxoma, and LV apical aneurysm (2% each). As a consequence of MDCT angiography findings, new management strategies were instituted in 15 of 50 patients (30%), including surgical correction of coronary artery anomalies of wrong sinus origin, ascending aneurysm graft repair, thrombolytic therapy for pulmonary embolism, and myxoma resection. Approximately 1% of patients undergoing MDCT angiography for suspicion of CAD proved to have otherwise unsuspected, but clinically relevant, cardiovascular abnormalities unrelated to coronary atherosclerosis. Almost one-third of these patients had cardiovascular diseases with major clinical implications for subsequent therapy. These findings underscore the value of MDCT angiography and the importance of careful assessment of scans for the recognition of a variety of cardiovascular abnormalities.

Is thrombolysis for intermediate-risk pulmonary embolism beneficial? The case of Emeritus Professor Crow

The methodologist’s point of viewAlessandro Squizzato, Lorenzo MojaYou are the attending physician on duty at the EmergencyDepartment, when John Crow, a 69-year-old EmeritusProfessor of cardiology comes with acute dyspnoea [1].The day before he started complaining a right leg oedemaand pain, he said. While starting to collect other clinicaldata and requiring tests you remember that time you metDr. Crow on a luxurious conference. Was he the onesupporting prescription of hormone replacement therapy towomen on the mistaken basis that this would reduce therisk of heart? Dr. Crow’s blood pressure is 120/80 mmHg.Spiral computed tomography shows emboli in more than50% of pulmonary vessels and a right ventricularenlargement. Blood troponin level is elevated and echo-cardiography confirm right ventricular enlargement.The resident on duty, who is just back from an inter-national meeting on venous thromboembolic diseases, isaware of the recently published European Society ofCardiology (ESC) guidelines and of the American Collegeof Chest Physicians (ACCP) on this topic that suggest thatabsolute indications for thrombolysis are: massive pul-monary embolism with persistent hypotension or shock[2, 3]. This is not your case. Your colleague reportsthat thrombolysis may be an option in selected cases ofsub-massive pulmonary embolism (PE) defined as normalblood pressure and right ventricular dysfunction [2, 3]. Thisis your case. Indeed, before discussing with this decla-mated patient the convenient therapeutic strategy, you needto clarify the advantages and the risks of adding throm-bolysis to heparin, which is your reference therapy. Youhave a look at the Cochrane Library and downloadthe systematic review entitled Thrombolytic therapy forpulmonary embolism [4].The Cochrane’s point of view: a systematic reviewOverall 679 patients were enrolled in 8 included random-ised controlled trials [4]. Different types of thrombolysis—alteplase, urokinase, streptokinase—were used and werecompared with heparin alone. All trials excluded patientswith high-risk PE, i.e. shock or persistent hypotension. Fiveof the eight trials had well reported and satisfactorymethodological quality. Clinically sound outcomes wereinconclusive: death rate odds ratio (OR) 0.89 [95% confi-dence interval (CI) 0.4–1.78]; major haemorrhagic eventsOR 1.61 (95 CI 0.91–2.86). Thrombolytics improved somesecondary outcomes—hemodynamic outcomes, perfusion

Predictors of In‐Hospital and Long‐Term Clinical Outcome in Elderly Patients with Massive Pulmonary Embolism Receiving Thrombolytic Therapy

To determine the clinical, historical, and instrumental findings associated with unfavorable short-term and long-term prognosis in elderly patients (>or=65) receiving thrombolytic therapy for pulmonary embolism (PE). Case-control retrospective study. General medicine acute care ward. Sixty-seven elderly patients with PE complicated by hemodynamic instability (massive PE) admitted to the "Antonio Cardarelli" Hospital from January 1, 2002, to December 31, 2004, and evaluated during their hospital stay and 174.4+/-4.6 days after discharge. PE diagnosis was confirmed using spiral computed tomography angiography. Hemodynamic instability was defined as cardiogenic shock and systolic blood pressure less than 90 mmHg or a pressure drop of 40 mmHg or more for longer than 15 minutes not due to new-onset arrhythmia, hypovolemia, or sepsis. Weight-adapted unfractionated heparin and recombinant tissue plasminogen activator. Nine patients (13.4%) died during hospitalization. Higher troponin-I (cTn-I) serum levels at admission to the emergency department and the occurrence of thrombocytopenia after thrombolysis were significantly associated with in-hospital death. Nineteen of the 58 survivors (32.7%) died during follow-up. The risk factors for long-term death were historical findings of cancer and cardiovascular disease at hospital admission. Higher cTn-I serum levels in the acute phase and the occurrence of thrombocytopenia after thrombolysis were significantly associated with in-hospital mortality in elderly patients with massive PE. In the same setting, historical findings of cancer and cardiovascular disease are strong predictors of death in the long term.

Stable Patients with RV Enlargement and PE: Thrombolyze or Not?

Thrombolytic therapy for pulmonary embolism (PE) in patients with evidence of right-ventricular (RV) dilatation, but without shock, is controversial.

Sciatic Nerve Palsy Due to Hematoma After Thrombolysis Therapy for Acute Pulmonary Embolism After Total Hip Arthroplasty

Sciatic nerve paralysis as a complication of bleeding due to hip surgery is a rare entity. The use of thrombolysis and full-dose heparin administration for the treatment of massive pulmonary embolism increase the risk for developing major bleeding. Prompt recognition and intervention in this condition are warranted. A case of sciatic nerve palsy due to expanding thigh hematoma as a complication of thrombolytic therapy for pulmonary embolism after total hip arthroplasty is presented with a literature review. Although rare, this complication should be promptly recognized and immediate decompression should take place because of the favorable results of the early treatment.

Thrombolytic Therapy for Pulmonary Embolism: Lessons from Recent Clinical Trials

Pulmonary embolism is a common disease that is associated with significant mobility and mortality. Thrombolysis is potentially life saving when used in conjunction with anticoagulant therapy. Indications for thrombolysis for pulmonary embolism are not well defined. In patients with acute massive pulmonary embolism and hypotension, thrombolytic therapy offers some benefits in terms of mortality reduction. The use of thrombolysis in patients with stable haemodynamics has been controversial for more than two decades. Recent clinical studies have indicated that thrombolytic treatment in conjunction with heparin in patients with submassive pulmonary embolism and normal blood pressure can prevent deterioration of the disease and diminish the need for more intensive therapies during hospitalisation. The role of prehospital thrombolytic therapy for acute pulmonary embolism is unclear and further clinical studies are warranted.

Thrombolytic therapy of pulmonary embolism. A meta-analysis

Thrombolytic therapy of pulmonary embolism. A meta-analysis

Thrombolytic therapy in pulmonary embolism.

Successfully utilized contemporary pulmonary embolism (PE) thrombolysis reverses right heart failure rapidly and safely. This therapeutic approach may lower mortality from PE and reduce morbidity from chronic pulmonary hypertension. PE thrombolysis remains a debatable indication because large clinical trials using survival as an endpoint have not been carried out. Instead, thrombolysis trials have been undertaken with surrogate endpoints such as reduction in clot burden, reduction in pulmonary arterial pressure, and improvement in right ventricular function. Currently, the only contemporary thrombolytic regimen for PE that is approved by the Food and Drug Administration is recombinant tissue plasminogen activator, in a dose of 100 mg/2 h. New thrombolytic agents under development for PE include reteplase, saruplase, and recombinant staphylokinase. Future clinical trials will require multicenter collaboration and focus on clinically relevant endpoints such as reduction of mortality and recurrent venous thromboembolism, under particular consideration of the risk of intracranial hemorrhage that ranges between about 1.7% in clinical trials up to approximately 3.0% in a large registry.

A contemporary approach to thrombolytic therapy for pulmonary embolism.

Successfully utilized contemporary pulmonary embolism thrombolysis reverses right heart failure rapidly and safely. This therapeutic approach may lower mortality from pulmonary embolism and reduce morbidity from chronic pulmonary hypertension. Unlike myocardial infarction thrombolysis, a 2-week 'time window' is available, during which treatment can be initiated. A high concentration of the thrombolytic agent is administered in a brief infusion lasting several hours. No special laboratory testing is needed. Currently, the only contemporary thrombolytic regimen for pulmonary embolism that is approved by the Food and Drug Administration is tissue plasminogen activator, in a dose of 100 mg/2 h. New thrombolytic agents under development for pulmonary embolism include reteplase, saruplase, and recombinant staphylokinase. Future clinical trials will require multicenter collaboration and will focus on relevant endpoints such as the reduction of mortality and recurrent venous thromboembolism.

A contemporary approach to thrombolytic therapy for pulmonary embolism

A contemporary approach to thrombolytic therapy for pulmonary embolism

Thrombolytic therapy in pulmonary embolism. Which patient should be treated, which regimen should be used?

The indications of thrombolytic therapy in the management of pulmonary embolism remain unclear. Thrombolysis is a lifesaving procedure in patients with major embolism and cardiogenic shock, but in patients with normal blood pressure, randomized studies did not show a decrease in mortality in patients receiving thrombolysis. Recent data however suggest that this therapy may be beneficial in patients with major pulmonary embolism and evidence of right ventricular afterload.

82-Year-Old Man With Recurrent Syncope

82-Year-Old Man With Recurrent Syncope

Thrombolytic Therapy of Pulmonary Embolism: A Comprehensive Review of Current Evidence

Pulmonary embolism (PE) is a common disorder that is accompanied by significant morbidity and mortality. Although anticoagulation is the standard treatment for PE, thrombolytic therapy, with its ability to produce rapid clot lysis, has long been considered an attractive alternative. Although many studies have been performed over the past three decades, however, the indications for the use of thrombolytic agents in patients with PE remain controversial. In this article, we review the medical literature and provide evidence-based guidelines for the use of thrombolytic therapy. We will also discuss the practical aspects of PE thrombolysis.

Prognosis in acute pulmonary embolism

Pulmonary embolism is a potentially fatal disease. In a study published 39 years ago in The Lancet, Barritt and Jordan reported that anticoagulant therapy reduces mortality in patients with a clinical diagnosis of pulmonary embolism. 1 Barritt DW Jordan SC Anticoagulant drugs in the treatment of pulmonary embolism: a controlled trial. Lancet. 1960; i: 1309-1312 Abstract Scopus (1076) Google Scholar Currently, most patients presenting with “submassive” pulmonary embolism are treated with an initial course of intravenous unfractionated heparin or subcutaneous low-molecular-weight heparin, followed by at least 3–6 months of oral anticogulant therapy. Although most clinicians agree that thrombolytic therapy is indicated in pulmonary embolism associated with shock, its role in patients with submassive pulmonary embolism remains controversial. Some clinicians have suggested that the indications for thrombolysis should be expanded to include haemodynamically stable patients with echo-cardiographic evidence of impaired right-ventricular dysfunction. 2 Goldhaber SZ Haire WD Feldstein ML et al. Altepase versus heparin in acute pulmonary embolism: randomised trial assessing right-ventricular dysfunction and pulmonary perfusion. Lancet. 1993; 341: 507-511 Summary PubMed Scopus (746) Google Scholar , 3 Ribeiro A Lindmarker P Juhlin-Dannfelt A Johnsson H Jorfeldt L Echocardiography doppler in pulmonary embolism: right ventricular dysfunction as a predictor of mortality rate. Am Heart J. 1997; 134: 479-487 Summary Full Text Full Text PDF PubMed Scopus (470) Google Scholar Others, however, argue that the potential benefits of thrombolytic therapy in this subset of patients are likely to be offset by an increase in major bleeding. 4 Dalen JE Alpert JS Hirsh J Thrombolytic therapy for pulmonary embolism. Arch Intern Med. 1997; 157: 2550-2556 Crossref PubMed Google Scholar Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER)PE remains an important clinical problem with a high mortality rate, Data from ICOPER provide rates and highlight adverse prognostic categories that will help in planning of future trials of high-risk PE patients. Full-Text PDF

The role of thrombolytic therapy in pulmonary embolism

The presence of thrombus in the deep venous system is not normal. In some cases, it is well tolerated because it is not occlusive and because the body has an intrinsic ability to dissolve thrombus to an extent. Where a large amount of thrombus blocks a vessel, symptoms and signs of the abnormal condition can be immediate and alarming. Unfortunately, the process of thrombus accumulation in the deep veins is often silent and unexpected. More unfortunate is the fact that embolization of thrombus, from extremity veins to the pulmonary arteries, is unpredictable and seemingly random. It is known that anticoagulation tends to halt thrombus propagation. However, to most individuals, it seems intuitively better if thrombus is not present at all. When it is, early removal with thrombolytic agents, or thrombectomy devices might be an advantage if thrombus is not present, it cannot embolize, or damage valves. If the process required to remove the thrombus was inexpensive and risk-free, there would be little discussion or hesitation. However, the risk/benefit ratio of thrombus removal, whether in peripheral or central veins and arteries, is a subject of great debate. Careful studies and complete long-term follow-up data are necessary for the thrombolytic option to evolve, to develop safe and effective use of this powerful therapeutic tool. The presence of thrombus in the deep venous system is not normal. In some cases, it is well tolerated because it is not occlusive and because the body has an intrinsic ability to dissolve thrombus to an extent. Where a large amount of thrombus blocks a vessel, symptoms and signs of the abnormal condition can be immediate and alarming. Unfortunately, the process of thrombus accumulation in the deep veins is often silent and unexpected. More unfortunate is the fact that embolization of thrombus, from extremity veins to the pulmonary arteries, is unpredictable and seemingly random. It is known that anticoagulation tends to halt thrombus propagation. However, to most individuals, it seems intuitively better if thrombus is not present at all. When it is, early removal with thrombolytic agents, or thrombectomy devices might be an advantage if thrombus is not present, it cannot embolize, or damage valves. If the process required to remove the thrombus was inexpensive and risk-free, there would be little discussion or hesitation. However, the risk/benefit ratio of thrombus removal, whether in peripheral or central veins and arteries, is a subject of great debate. Careful studies and complete long-term follow-up data are necessary for the thrombolytic option to evolve, to develop safe and effective use of this powerful therapeutic tool.