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thrombolysis for pulmonary embolism

Indications: 1) massive or submassive pulmonary emboli 2) hemodynamically unstable Contraindications: - high risk of bleeding - age is not a contraindication [1] - comordidites are not a contraindication [1] Procedure: 1) thrombolytic agents a) streptokinase b) urokinase c) recombinant tissue plasminogen activator (Alteplase) - 50 mg total dose (max) - 10 ug bolus followed by 40 mg infusion over 2 hours -= 0.5 mg/kg total dose for patients weighing <50 kg 2) heparin therapy is necessary after thrombolytic therapy * use full dose thrombolytic agent * 1/2 dose alteplase associated with additional thrombolytic therapy or mechanical thrombectomy [5] Clinical significance: - thrombolysis decreases mortality relative to anticoagulation (3.9% vs. 2.2%) - but increases major bleeding (9.2% vs. 3.4%), including intracranial hemorrhage (1.46% vs. 0.19%) - the increased bleeding risk significant only for patients > 65 years of age [4] Notes: - unstable patients with pulmonary embolism are less likely to receive thrombolytic therapy if they are elderly or have comorbid conditions [1] - those who receive thrombolytic therapy have a lower in-hospital case fatality rate regardless of age or comorbid conditions [1]

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pulmonary embolism (PE)

General

thrombolytic therapy

References

  1. Stein PD, Matta F. Treatment of unstable pulmonary embolism in the elderly and those with comorbid conditions. Am J Med. 2013;126(4):304-310 PMID: 23415054 - Dalen JE. Editorial: Thrombolytics decrease mortality in elderly patients with unstable pulmonary embolism. Am J Med. 2013;126(4):278-279 PMID: 23369210
  2. Sharifi M et al. Moderate pulmonary embolism treated with thrombolysis (from the "MOPETT" trial). Am J Cardiol 2013 Jan 15; 111:273. PMID: 23102885
  3. Meyer G et al. Fibrinolysis for patients with intermediate-risk pulmonary embolism. N Engl J Med 2014 Apr 10; 370:1402. PMID: 24716681 http://www.nejm.org/doi/full/10.1056/NEJMoa1302097
  4. 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):2414-2421 PMID: 24938564 http://jama.jamanetwork.com/article.aspx?articleid=1881311 - Beckman JA Thrombolytic Therapy for Pulmonary Embolism. JAMA. 2014;311(23):2385-2386 PMID: 24938561 http://jama.jamanetwork.com/article.aspx?articleid=1881294
  5. Kiser TH, Burnham EL, Clark B et al. Half-dose versus full-dose alteplase for treatment of pulmonary embolism. Crit Care Med 2018 Jul 2; PMID: 29979222 https://insights.ovid.com/crossref?an=00003246-900000000-96212