Guidelines recommend that patients with massive pulmonary embolism (PE) and hemodynamic instability be treated with thrombolysis (Circulation 2011; 123:1788). However, consensus is lacking on what to do in intermediate-risk patients (i.e., those who are hemodynamically stable but have right ventricular dysfunction). Investigators performed a meta-analysis of 16 trials conducted during the last 45 years of thrombolysis for PE. Of 2115 patients, most (71%) were classified as having intermediate-risk PE; 9.9% had low-risk PE; and 1.5% had hemodynamically unstable, high-risk PE. Risk could not be classified in the remaining patients.
At mean follow-up of 82 days, all-cause mortality was significantly lower overall in patients who received thrombolytic therapy versus anticoagulant therapy (2.2% vs. 3.9%), but major bleeding was significantly higher (9.2% vs. 3.4%), as was intracranial hemorrhage (1.5% vs. 0.2%); results were similar when only patients with intermediate-risk PE were considered. Among patients older than 65, major bleeding was significantly more common with thrombolysis than with anticoagulant therapy (13% vs. 4%). Outcomes were no different in analyses that excluded the single trial that involved catheter-directed thrombolysis.
Chatterjee S et al. Thrombolysis for pulmonary embolism and risk of all-cause mortality, major bleeding, and intracranial hemorrhage: A meta-analysis. JAMA 2014 Jun 18; 311:2414. Link.