Accelerated Thrombolysis for Pulmonary Embolism

] Recently, several studies have addressed thrombolytic therapy in patients with submassive PE. The Pulmonary Embolism International Thrombolysis (PEITHO) trial reported a substantial reduction in the combined endpoint of early mortality or hemodynamic collapse in patients receiving systemic thrombolysis (compared with heparin alone) at the expense of a significant increase in major hemorrhage (including intracranial hemorrhage). This was particularly evident among elderly patients aged >75 years. In the much smaller Tenecteplase or Placebo: Cardiopulmonary Outcomes At Three Months (TOPCOAT) study, which was terminated prematurely, the composite primary outcome (5-day survival to hospital discharge without shock, intubation, or major hemorrhage; 90-day rate of normal right ventricular function, 6-minute walk distance >330 m, no dyspnea at rest, and no recurrent PE or deep vein thrombosis) was positive in the patients randomized to thrombolysis compared with the low-molecular-weight heparin patients. Another small study comparing thrombolytic therapy with heparin alone demonstrated a decrease in the composite endpoint of death, recurrent venous thromboembolism, right ventricular dysfunction, and major hemorrhage at 6 months in the group randomized to thrombolytic therapy. 9 In the Moderate Pulmonary Embolism Treated with Thrombolysis (MOPPETT) trial, half-dose systemic thrombolytic therapy resulted in longterm reduction in the incidence of pulmonary hypertension compared with anticoagulation alone without excess bleeding.