Thrombolysis in Sub-Massive PE

I gave this talk on the controversial topic of thrombolysis in submassive (intermediate-risk) PE for a CME session recently. This group of patients is defined as those with a PE who  are not haemodynamically compromised, even if there is echocardiographic or laboratory evidence of right ventricular strain. Here is the slide deck for anyone who wants to relive that wonderful hour.

 

 

 

My take on the conclusion: there is insufficient evidence to support the use of thrombolysis in intermediate-risk, nonmassive PE. If, however, your patient deteriorates into a haemodynamically unstable condition, then thrombolysis can be given then.

But, if you want to cherry pick data to build your argument...

  • There may be a lower mortality rate with thrombolysis (on meta-analysis only, which has some significant methodological flaws and includes heterogeneous trials)
  • There may be lower rates of long-term pulmonary hypertension (MOPETT, with a control rate of 57%)
  • There doesn't seem to be an increase in significant bleeds in younger patients (meta-analysis)
  • Maybe 1/2 dose thrombolysis works just as well and carries less risk (MOPETT)

On the other hand, the largest trial (PEITHO) found no improvement in mortality, but a significant increase in major bleeds, and concluded:

...great caution is warranted when considering fibrinolytic therapy for hemodynamically stable patients with pulmonary embolism, right ventricular dysfunction, and a positive cardiac troponin test.

I don't think we can argue with that.

 

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