SFGH 3.11 AM REPORT PEARLS: Thrombolytics for Intermediate-Risk PE

Submassive PE

Typically defined as acute PE without systemic hypotension (SBP ≥ 90 mmHg) and with either RV dysfunction or myocardial necrosis.

RV dysfunction is the presence of one of the following:

  • RV dilation or RV systolic dysfunction on echocardiography
  • RV dilation on CT
  • Elevation of BNP (> 90 pg/mL)
  • Elevation of N-terminal pro-BNP (> 500 pg/mL)
  • ECG changes c/w RV dysfunction (new complete or incomplete RBBB, anteroseptal ST elevation or depression, or anteroseptal T-wave inversion)

Myocardial necrosis is defined as one of the following:

  • Elevation of troponin I (> 0.4 ng/mL)
  • Elevation of troponin T (> 0.1 ng/mL)

Thrombolysis for PE

Larissa reviewed the main findings of the meta-analysis (attached here) by Chatterjee et al. published in JAMA in 2014.

Here are the highlights:

  • Meta-analysis of 16 RCTs (n=2115)
  • 4 trials accounted for 74% of the total patients (2 of these trails were MAPPETT-3 and PEITHO).
  • Results
    • NNT = 59 for all cause mortality benefit with ARR of 1.12%
    • NNH = 18 for major bleeding event
      • Notably, major bleeding was not significantly increased in patients 65 years and younger (OR 1.25; 95% CI 0.5-3.14)
    • Use of thrombolytics + anticoagulation was associated with lower all-cause mortality (OR 0.53; 95% CI, 0.32-0.88)
    • Thrombolysis was associated with a lower risk of recurrent PE (OR 0.40; 95% CI 0.22-0.74; NNT = 54)
  • The analysis also reviewed thrombolytics for intermediate-risk PE. Intermediate-risk PE was defined as patients who were hemodynamically stable but had e/o RV dysfunction.
  • Obviously, study heterogeneity was present among the studies and this was due to variations in definitions for hemodynamic instability, major and minor bleeding, definition of RV dysfunction, and doses/types of thrombolysis used.

Bottom Line/Takeaway

The meta-analysis suggests that there is a potential mortality benefit with thrombolytic therapy in patients with hemodynamically stable PE with RV dysfunction and that the risk of major bleeding associated with thrombolytic therapy is not significantly increased in patients under the age of 65.

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