Increased Prevalence of Sleep-Disordered Breathing among Professional Football Players

Thrombolytic Therapy in Patients with Submassive Pulmonary Embolismto the editor: Konstantinides et al. (Oct.10 issue) 1 evaluated the role of alteplase in patients with submassive pulmonary embolism.Their findings will be regarded by many as definitive evidence in support of the use of thrombolytic agents in such patients.However, a review of the study design, particularly the end points chosen, shows that the data do not support the authors' conclusions.The only primary end point to show significant improvement was an escalation of treatment for clinical deterioration -nearly always meaning treatment with open-label alteplase, the drug used in the intervention group.The decision to escalate treatment was made by clinicians, who were permitted to break the randomization code first; thus, the primary end point in a given case could be determined by an unblinded provider.Escalation of treatment would have been unlikely in a patient with clinical deterioration who was in the alteplase group but would have been likely in a patient with similar deterioration who was in the placebo group.The study suggests that the number needed to treat was nine; in other words, nine patients would have to be given alteplase to avoid treatment escalation (i.e., use of open-label alteplase) in one patient.In view of the 1 percent risk of major hemorrhage with thrombolysis, 2 avoiding open-label use in one patient hardly justifies preemptive use of the drug in many more patients.