Single-center experience with thrombolysis in high- and intermediate-risk pulmonary embolism

N. Herr, C. Bode, T. Wengenmayer, D. Duerschmied (Freiburg, Germany)

Antithrombotic treatment
Date: 17.02.2017,
Time: 17:15 - 18:15

Objective: Pulmonary embolism (PE) is a potentially life-threatening acute cardiovascular syndrome. While thrombolysis is the guideline-recommended standard of care treatment for high-risk patients (in shock), it may be considered in a subset of intermediate-risk patients (at risk for shock). The individual bleeding risk must be considered in the decision-making. Aims: We report single center registry data with 30-day mortality to evaluate guideline-recommended treatment algorithms.

Methods: We followed 74 patients with pulmonary embolism either at high- or intermediate risk (all-comers, 2013-2016). Patients at intermediate risk were treated with alteplase (rtPA), either full- (100 mg) or low-dose (0.6mg/kg, 50mg max) at the treating physician’s discretion when these patients were considered at especially high risk or had already signs of hemodynamic decompensation.

Results: Thirty-three (45%) of the 74 patients were at intermediate risk. The average age of the patients at intermediate risk was 65,3 years vs. 64,8 years in the patients at high risk. Fifteen of the patients at intermediate risk (45%) received thrombolysis. 7 were treated at full dose and 8 with low dose. All patients at high risk received full-dose thrombolysis. The survival in the intermediate risk group was 100%, compared to 57% (25 patients) in the high risk group. In the intermediate risk group, relevant bleedings occurred in 2 patients (6%, one case of pulmonary and one case of intraarticular bleeding) while in the high risk group in 19 patients (46%) had relevant bleedings. There was no intracerebral bleeding in patients at intermediate risk compared to 2 (5%) in patients at high risk.

Conclusion: The 30-day survival of patients at intermediate risk PE was 100%, after approximately half of these patients had received thrombolysis. The risk of relevant bleedings in patients at intermediate risk receiving thrombolysis was relatively low – possibly because half of them received low-dose alteplase. According to current guideline recommendations, the choice for thrombolysis in intermediate-risk PE patients needs to take into account each individual patient’s risk for bleeding and PE-related death and these data reinforce this approach. Patients with a low bleeding risk and at younger age appeared to benefit from thrombolysis and low-dose alteplase was safe.