Key result
Systemic thrombolysis fails to reduce in-hospital mortality vs anticoagulation in acute intermediate-risk PE.
Why the study?
Prior trials comparing systemic thrombolysis to anticoagulation in intermediate-risk PE yielded mixed results, and earlier meta-analyses included non-standard doses and unavailable agents.
Does systemic thrombolysis with newer thrombolytics reduce in-hospital mortality compared to anticoagulation in acute intermediate risk pulmonary embolism?
Meta-Analysis (n=1,755)
Does systemic thrombolysis with newer thrombolytics reduce in-hospital mortality compared to anticoagulation in acute intermediate risk pulmonary embolism?
Relative Risk: 0.79 (95% CI 0.42–1.5)
p-value: p=0.47
In intermediate-risk pulmonary embolism, systemic thrombolysis with newer agents does not improve in-hospital mortality and increases the risk of intracranial hemorrhage compared to anticoagulation alone, despite reducing the need for vasopressors and rescue thrombolysis.
No mortality benefit with higher intracranial hemorrhage risk cautions against routine use in intermediate-risk PE; extends prior analyses using contemporary agents and standard doses.
Background Randomized controlled trials (RCTs) comparing systemic thrombolysis to anticoagulation in intermediate risk pulmonary embolism (PE) have yielded mixed results. A prior meta-analysis on this topic had included studies that used lower than standard dose of thrombolytics and included thrombolytic agents that are no longer available. Hence, interpreting the findings of that paper is not valid in contemporary practice. Objectives We undertook a systematic review and meta-analysis of randomized controlled trials of systemic thrombolysis with newer thrombolytic agents vs anticoagulation in intermediate risk PE. Methods This systematic review and meta-analysis is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Results Nine randomized controlled trials were included in the study. We did not find any difference in in-hospital mortality (RR: 0.79; 95% CI: 0.42–1.50; I 2 : 0) or risk of major bleeding (RR:2.08;95% CI: 0.98–4.42; I 2 : 23.9%) between systemic thrombolysis and anticoagulation. Systemic thrombolysis was associated with lower risks for vasopressor use (RR: 0.27; 95% CI: 0.11–0.64, I 2 : 0) and secondary/rescue thrombolysis (RR: 0.25; 95% CI: 0.14–0.45; I 2 : 0). But systemic thrombolysis was found to have an increased risk of intracranial hemorrhage (RR: 4.55; 95% CI: 1.30–15.91; I 2 :0). There was no difference in mechanical ventilation between the two groups (RR: 0.61; 95% CI: 0.31–1.19, I 2 :0). Conclusion In our meta-analysis of randomized controlled trials of systemic thrombolysis vs anticoagulation in intermediate risk PE, we did not find any difference in in-hospital mortality or overall risk of major bleeding. With systemic thrombolysis, we found lower risks for vasopressor use and need for secondary/ rescue thrombolysis and an increased risk of intracranial hemorrhage.
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Mathew et al. (2023) conducted a meta-analysis in Acute intermediate risk pulmonary embolism (n=1,755). Systemic thrombolysis vs. Anticoagulation was evaluated on In-hospital mortality (RR 0.79, 95% CI 0.42-1.50, p=0.47). Systemic thrombolysis did not significantly reduce in-hospital mortality (RR 0.79) compared to anticoagulation in patients with acute intermediate-risk pulmonary embolism.
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