Clinical StudiesIncidence and predictors of major hemorrhagic complications from thrombolytic therapy in patients with massive pulmonary embolism
Section snippets
Patients
We retrospectively analyzed the hospital records of all patients who received recombinant tissue-type plasminogen activator for massive pulmonary embolism in our hospital between November 1988 and March 1994. All but four patients had pulmonary embolism objectively diagnosed by selective bilateral pulmonary angiography. Massive pulmonary embolism was defined by a pulmonary vascular obstruction score >20/34 (ie, >60%) according to the criteria of Miller et al (15). The four remaining patients
Results
Between 1988 and 1994, 132 consecutive adult patients received intravenous alteplase for massive pulmonary embolism. There were 57 men (43%) and 75 women with a mean age of 66 years (range: 19 to 88 years). Nineteen patients (14%) received 100 mg alteplase over 2 hours, 61 (46%) received 1 mg/kg over 10 minutes, and 52 (39%) received 0.6 mg/kg over 10 minutes.
Ten patients (8%) died during the hospital stay, including two from bleeding (one patient with intracranial bleeding, another with
Discussion
Bleeding, particularly when pulmonary angiography was performed via femoral access site, was a frequent complication of thrombolytic treatment in patients with pulmonary embolism. The 25% rate of major bleeding that we observed is somewhat greater than those reported in trials of thrombolytic treatment of patients with pulmonary embolism (12), though the 1.5% incidence of intracranial hemorrhage was similar to that recently reported (11). However, the use of different definitions of major
Conclusion
In patients with massive pulmonary embolism diagnosed invasively, the use of a superficial arm vein for performing angiography may reduce thrombolysis-induced bleeding complications. The comparability of clinical trials on thrombolysis in pulmonary embolism would benefit from the use of more reproducible methods for estimating the bleeding rate.
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Cited by (73)
Prevention of early complications and late consequences after acute pulmonary embolism: Focus on reperfusion techniques
2018, Thrombosis ResearchCitation Excerpt :In the 1990′s, a study by Meyer and colleagues included 132 consecutive patients treated at a single institution who received rtPA [18]. The authors reported that the use of the femoral vein access for pulmonary angiography was the only variable associated with major bleeding; however, the use of different definitions of major bleeding contributed to large differences in the observed rates [18]. In the Management Strategies and Prognosis of Pulmonary Embolism (MAPPET) study, a randomized controlled trial with clinical endpoints, systemic thrombolysis resulted in an almost two-fold increase in major bleeding rate in women (27%, vs 15% in men) [20].
Systemic Thrombolysis for Pulmonary Embolism: Who and How
2017, Techniques in Vascular and Interventional RadiologyCitation Excerpt :Certain surgeries or a gastrointestinal bleed might potentially be only a relative contraindication if the patient is in shock with impending cardiac arrest. In patients with contraindications to thrombolytic therapy, surgical embolectomy or mechanical embolectomy may be considered.26,27 When there is a high clinical suspicion of PE, and in the absence of contraindications, anticoagulation should be initiated while the diagnostic workup is being completed.
Thrombolysis in hemodynamically stable patients with acute pulmonary embolism: A meta-analysis
2014, Thrombosis ResearchCitation Excerpt :Whether a screening for the risk of bleeding in hemodynamically stable patients with acute PE could move the benefit balance in favor of thrombolysis is unclear. Some studies have identified increasing age, diastolic hypertension, BMI > 30 Kg/m2 and invasive procedures as predictors of MB [28–32]. However, there are no validated explicit clinical prediction scores that stratify bleeding risk in patients with PE receiving thrombolysis.
Thrombolytic therapy for submassive pulmonary embolism
2012, Best Practice and Research: Clinical HaematologyMortality Risk Assessment and the Role of Thrombolysis in Pulmonary Embolism
2011, Critical Care ClinicsMortality risk assessment and the role of thrombolysis in pulmonary embolism
2010, Clinics in Chest MedicineCitation Excerpt :Noninvasive diagnostic strategies have increasingly been adopted over the past 10 years thanks to the technical advances in computed tomographic (CT) pulmonary angiography.24 On the other hand, retrospective cohort studies and registries have suggested a 36% incidence of major bleeding events and a 4% rate of intracranial/fatal hemorrhage following thrombolysis for PE.4,5,56,57 These rates may be inappropriately high, because registries are likely to include patients who have received thrombolysis despite the presence of formal contraindications.5