Pulmonary emboli. To thrombolyse or not to thrombolyse…?!!

It’s the age old adage…do you or don’t you, is the outcome better or worse?? Age, morbidity, mortality, recent surgery….does it save lives?? Are you better to admit them to ITU and watch with advanced monitoring and take the gamble…

Thrombolysing someone with M.I used to be done at the drop of a hat. But PE, the jury is still out! It seems to me that the key is physiological robustness within age…

Here is a fabulous discussion within one of the ICU case summaries regarding exactly this issue.

If you look in the menu bar on the right, you can find and download one of our presentations regarding a similar case. Within which we discuss the evidence behind what should form our clinical judgement. Thanks to my colleague David Popple for this one.

Link also here.

Their synopsis in this patient and sub categories of patients:

  • Current evidence does not support the routine use of thrombolytic therapy in haemodynamically stable patients with acute PE.
  • It is still unclear whether long-term sequelae may be prevented by use of thrombolysis in the acute setting; further research is needed to address this.
  • The rate of major haemorrhage in all patients receiving thrombolysis for PE is approximately 10-fold higher compared to standard anticoagulation with heparin alone.7,10,11
  • Haemodynamically stable patients under 66 years of age with RV dysfunction and myocardial injury may have a significant reduction in mortality and no significantly increased risk of major haemorrhage when given thrombolytics.10,11
  • In patients with intermediate-risk PE, haemodynamic decompensation and a high bleeding risk, other options for reperfusion include surgical embolectomy or percutaneous catheter-directed thrombolysis where facilities for this exist

Consider the use of thrombolysis in young patients with a low risk of bleeding, who present with acute PE and significant right ventricular dysfunction.

There remains an overall low mortality rate from intermediate-risk PE (2.92%) and high bleeding risk from thrombolysis (2.84%), therefore balancing these risks is challenging requiring individual consideration of each case. A bleeding complication in the elderly could be potentially life threatening with a high risk of long-term disability.

In patients over 65 years we agree too that we would not support the use of thrombolysis for PE unless there was significant haemodynamic compromise, at which time the risk of major haemorrhage should be fully discussed with the patient and relatives.

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