Thrombolytics for pulmonary embolism: Difference between revisions
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==Overview== | ==Overview== | ||
*For most hemodynamically stable patients, thrombolytic therapy is NOT indicated | |||
*'''Major controversy exists regarding thrombolytic therapy in submassive PE. Therapy should be individualized to patients.'''<ref>Elliott C. et al. Fibrinolysis of Pulmonary Emboli — Steer Closer to Scylla.</ref><ref>Sharifi M et al. Moderate pulmonary embolism treated with thrombolysis (from the “MOPPETT trial). J Cardiol 2013; 111: 273-7</ref><ref>Meyer G. Fibrinolysis for patients with intermediate-risk pulmonary embolism. NEJM 2014; 370(15): 1402-1411</ref> ''''The mortality benefit may be greatest in patients with right ventricular dysfunction.''' <ref>Chatterjee. S et al. Thrombolysis for pulmonary embolism and risk of all-cause mortality, major bleeding, and intracranial hemorrhage: a meta-analysis. JAMA 2014; 311(23):2414-21. PubMed ID: 24938564.</ref> | *'''Major controversy exists regarding thrombolytic therapy in submassive PE. Therapy should be individualized to patients.'''<ref>Elliott C. et al. Fibrinolysis of Pulmonary Emboli — Steer Closer to Scylla.</ref><ref>Sharifi M et al. Moderate pulmonary embolism treated with thrombolysis (from the “MOPPETT trial). J Cardiol 2013; 111: 273-7</ref><ref>Meyer G. Fibrinolysis for patients with intermediate-risk pulmonary embolism. NEJM 2014; 370(15): 1402-1411</ref> ''''The mortality benefit may be greatest in patients with right ventricular dysfunction.''' <ref>Chatterjee. S et al. Thrombolysis for pulmonary embolism and risk of all-cause mortality, major bleeding, and intracranial hemorrhage: a meta-analysis. JAMA 2014; 311(23):2414-21. PubMed ID: 24938564.</ref> | ||
Revision as of 00:45, 21 June 2019
Overview
- For most hemodynamically stable patients, thrombolytic therapy is NOT indicated
- Major controversy exists regarding thrombolytic therapy in submassive PE. Therapy should be individualized to patients.[1][2][3] 'The mortality benefit may be greatest in patients with right ventricular dysfunction. [4]
- Bleeding risk is increased with increasing age especially in the group ≥ 65 yo[5]
Indications
- Patients with massive PE and acceptable risk of bleeding complications
- Patient with submassive PE with evidence adverse prognosis + low risk of bleeding complications
- Hemodynamic instability
- Worsening respiratory insufficiency
- Severe Right Ventricular dysfunction
- Major myocardial necrosis
Evaluation
- Massive PE[6]
- Acute with
- Sustained hypotension (systolic blood pressure <90 mm Hg for at least 15 minutes or requiring inotropic support, not due to a cause other than PE, such as arrhythmia, hypovolemia, sepsis, or left ventricular [LV] dysfunction)
- Pulselessness
- Or, persistent profound bradycardia (heart rate <40 bpm with signs or symptoms of shock)
- Acute with
- Submassive PE[7]
- Acute without systemic hypotension (see above) but with either RV dysfunction or myocardial necrosis
- RV dysfunction means the presence of at least 1 of the following:
- RV dilation (apical 4-chamber RV diameter divided by LV diameter >0.9) or RV systolic dysfunction on echocardiography
- RV dilation (4-chamber RV diameter divided by LV diameter >0.9) on CT
- Elevation of BNP (>90 pg/mL)
- Elevation of N-terminal pro-BNP (>500 pg/mL); or
- Electrocardiographic changes (new complete or incomplete right bundle-branch block, anteroseptal ST elevation or depression, or anteroseptal T-wave inversion)
- Myocardial necrosis is defined as either of the following:
- Elevation of troponin I (>0.4 ng/mL) or
- Elevation of troponin T (>0.1 ng/mL)
- RV dysfunction means the presence of at least 1 of the following:
- Acute without systemic hypotension (see above) but with either RV dysfunction or myocardial necrosis
Contraindications
Absolute contraindications
- Any prior intracranial hemorrhage
- Known structural intracranial cerebrovascular disease (e.g. AVM)
- Known malignant intracranial neoplasm
- Ischemic stroke within last 3 months
- Suspected aortic dissection
- Active bleeding or bleeding diathesis
- Recent surgery encroaching on the spinal canal or brain
- Recent closed-head or facial trauma with radiographic evidence of bony fracture or brain injury
Relative contraindications
- Age >75 years
- Current use of anticoagulation
- PE in Pregnancy
- Noncompressible vascular punctures
- Traumatic or prolonged CPR (>10min)
- Recent internal bleeding (within 2 to 4 weeks)
- History of chronic, severe, and poorly controlled hypertension
- Severe uncontrolled hypertension on presentation (sys BP >180 or dia BP >110)
- Dementia
- Remote (>3 months) ischemic stroke
- Major surgery within 3 weeks
Administration
Administration regimens differ widely in the literature, options not in any particular order, include:
- Alteplase 0.6 - 1 mg/kg or 100 mg with any of the three possibilities
- Tenecteplase in at 50 mg bolus or 0.5 mg/kg bolus [12][13][14]
Related Instructions
- Review contraindications (below)
- After infusion complete measure serial aPTTs
- Almost all studies of thrombolysis administration included heparin anticoagulation
- Once value is <2x upper limit restart anticoagulation
- Ongoing CPR from 2010 AHA Guidelines is not an absolute contraindication, and some studies suggest permiting 15 min of CPR to allow thrombolysis to work[15]
- Discontinue heparin during infusion
Complications
See Also
- Thrombolytics
- Pulmonary embolism (main)
Thrombolytics for pulmonary embolism
- Clinical Page
- Research summary page: EBQ:Thrombolysis in Pulmonary Embolism Metanalysis
External Links
References
- ↑ Elliott C. et al. Fibrinolysis of Pulmonary Emboli — Steer Closer to Scylla.
- ↑ Sharifi M et al. Moderate pulmonary embolism treated with thrombolysis (from the “MOPPETT trial). J Cardiol 2013; 111: 273-7
- ↑ Meyer G. Fibrinolysis for patients with intermediate-risk pulmonary embolism. NEJM 2014; 370(15): 1402-1411
- ↑ Chatterjee. S et al. Thrombolysis for pulmonary embolism and risk of all-cause mortality, major bleeding, and intracranial hemorrhage: a meta-analysis. JAMA 2014; 311(23):2414-21. PubMed ID: 24938564.
- ↑ EBQ:Thrombolysis_in_Pulmonary_Embolism_Metanalysis#Outcomes
- ↑ Circulation 2011;123:1788
- ↑ Circulation 2011;123:1788
- ↑ Kürkciyan I, Meron G, Sterz F, et al. Pulmonary embolism as a cause of cardiac arrest: presentation and outcome. Arch Intern Med. 2000;160(10):1529-1535.
- ↑ Ruiz-Bailén M, Aguayo-de-Hoyos E, Serrano-Córcoles M, et al. Thrombolysis with recombinant tissue plasminogen activator during cardiopulmonary resuscitation in fulminant pulmonary embolism. A case series. Resuscitation. 2001;51(1):97-101.
- ↑ Kürkciyan I, Meron G, Sterz F, et al. Pulmonary embolism as a cause of cardiac arrest: presentation and outcome. Arch Intern Med. 2000;160(10):1529-1535.
- ↑ Abu-Laban R, Christenson J, Innes G, et al. Tissue plasminogen activator in cardiac arrest with pulseless electrical activity. N Engl J Med. 2002;346(20):1522-1528.
- ↑ Fatovich D, Dobb G, Clugston R. A pilot randomised trial of thrombolysis in cardiac arrest (The TICA trial). Resuscitation. 2004;61(3):309-313.
- ↑ Bozeman W, Kleiner D, Ferguson K. Empiric tenecteplase is associated with increased return of spontaneous circulation and short term survival in cardiac arrest patients unresponsive to standard interventions. Resuscitation. 2006;69(3):399-406.
- ↑ Böttiger B, Arntz H, Chamberlain D, et al. Thrombolysis during resuscitation for out-of-hospital cardiac arrest. N Engl J Med. 2008;359(25):2651-2662.
- ↑ Hayes BD. What’s the Code Dose of tPA? Updated August 2016. https://www.aliem.com/2013/whats-code-dose-of-tpa/.