Key result
Adding thrombolysis to anticoagulation shows no 30-day mortality benefit over anticoagulation alone in intermediate-risk PE.
Why the study?
The role of thrombolytic therapy in managing intermediate-risk pulmonary embolism remains controversial.
Does the addition of thrombolytic therapy (low-dose, full-dose, or catheter-directed) to anticoagulation reduce 7-day and 30-day mortality in patients with intermediate-risk pulmonary embolism compared to anticoagulation alone?
Cohort (n=257)
Yes
Does the addition of thrombolytic therapy (low-dose, full-dose, or catheter-directed) to anticoagulation reduce 7-day and 30-day mortality in patients with intermediate-risk pulmonary embolism compared to anticoagulation alone?
p-value: p=0.04
In patients with intermediate-risk pulmonary embolism, the addition of thrombolytic therapy to anticoagulation did not improve 30-day mortality but was associated with increased ICU resource utilization.
Does not support routine thrombolytic addition in intermediate-risk PE; leaves open need for randomized confirmation.
OBJECTIVE: The role of thrombolytic therapy in the management of intermediate-risk pulmonary embolism is controversial. Our objective was to determine clinical outcomes for a population of patients with intermediate-risk pulmonary embolism receiving anticoagulation with and without thrombolytic therapy in a large Northeastern health system. DESIGN: A retrospective cohort study. SETTING: ICU and non-ICU settings in 8 hospitals. PATIENTS: Hemodynamically stable patients with intermediate-risk pulmonary embolism. INTERVENTIONS: Treatment arms were anticoagulation (AC) alone, AC with low dose intravenous thrombolysis, AC with full-dose intravenous thrombolysis, and AC with ultrasound-assisted, catheter-directed thrombolysis. MEASUREMENTS AND MAIN RESULTS: In 257 patients, utilizing a Bonferroni corrected P value cutoff of α = 0.003, our data shows no differences in 7 day or 30 day all-cause mortality (α = 0.37 and α = 0.04, respectively) , hospital length of stay (α = 0.31), 7 or 30 readmission rates (α = 0.97 and α = 0.84, respectively), or any major (α = 0.82) or minor bleeding events (α = 0.007) among the four treatment groups. Use of anticoagulation alone was associated with a lower duration of ICU stay (α < 0.001). There was a significant decrease in the secondary outcome of one year all-cause mortality in favor of full dose and catheter-directed thrombolytic treatment (α = 0.003). Pulmonary artery systolic pressure of > 70 mmHg was associated with increased 7-day mortality (OR 7.79, P = 0.048), and systolic blood pressure < 130 (OR 23.0; P = 0.003) and elevated N-terminal pro-B-type natriuretic peptide > 1400 pg/nl (OR 15.33; P = 0.01) were associated with increased 30- day mortality. CONCLUSIONS: The use of thrombolytic therapy is not associated with a mortality benefit in the first 30 days compared to anticoagulation alone in this patient population and is associated with increased utilization of intensive care unit resources. We advocate for a conservative approach utilizing initial anticoagulation alone in a patient diagnosed with intermediate-risk pulmonary embolism.
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Jiang et al. (2021) conducted a cohort in Intermediate-risk pulmonary embolism (n=257). Thrombolytic therapy (low-dose, full-dose, or ultrasound-assisted catheter-directed) plus anticoagulation vs. Anticoagulation alone was evaluated on 30-day all-cause mortality (p=0.04). The addition of systemic or catheter-directed thrombolytic therapy to anticoagulation did not significantly improve 30-day all-cause mortality compared to anticoagulation alone in patients with intermediate-risk pulmonary embolism.
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