September 2015: Thrombolytics in Sub-massive Pulmonary Embolism

This month JC will be looking the use of thrombolytic agents in sub-massive PE. Recommendations regarding the use of thrombolysis in acute submassive PE are a bit disparate. The AHA has recommended in favor of using thrombolytics in subgroups of patients with evidence of right-heart strain or myocardial enzyme elevations. ACEP on the other hand claims that there is insufficient evidence for the use of thrombolytics in “any subgroup” of hemodynamically stable patients.  Some argue about the possible benefits of thrombolytics in long-term complications of PE such as Chronic Thromboembolic Pulmonary Hypertension (CTEPH).  Others argue that the paucity of good data regarding thrombolytics is not worth the risk of intracranial or other potentially fatal bleeding complications.  We will look at a few recent articles that attempt to add to current data. Should make for some interesting discussion.  Also included is a fun read from our Canadian colleagues. Seems they are well acquainted with the grind of practicing hallway medicine. As always, free to tweet your perspective

P: In patients presenting to the ED with acute PE and evidence of right heart strain

I: Does the use of thrombolytic therapy

C: Compared to Heparin, LMWH or other anticoagulants

O: Improve patient centered outcomes (Morbidity, Mortality, Quality of life)

ShariSi M, et al.  Moderate pulmonary embolism treated with thrombolysis The "MOPETT" Trial. Am J Cardiol. 2013 Jan 15;111(2):273-7.     Review

Kline JA, et al. Treatment of submassive pulmonary embolism with tenecteplase or placebo: cardiopulmonary outcomes at 3 months: multicenter double-blind, placebo-‐controlled randomized trial. J Thromb Haemost. 2014 Apr;12(4):459-68.      Review

Meyer G, et al.. Fibrinolysis for patients with intermediate-risk pulmonary embolism. PEITHO Investigators N Engl J Med. 2014 Apr 10;370(15):1402-11.      Review

The emerging subspecialty of Hallway Medicine Jeffrey Freeman, MD