Key result
Thrombolytics in stable PE fail to reduce death or recurrence but increase major bleeding ~235%.
Why the study?
Thrombolytic therapy is recommended only for high-risk PE, but is often used in hemodynamically stable patients despite uncertain risk-benefit compared to anticoagulant monotherapy.
Does thrombolytic therapy reduce mortality or recurrence of PE compared with unfractionated heparin monotherapy in hemodynamically stable patients with pulmonary embolism?
Meta-Analysis (n=1,611)
Does thrombolytic therapy reduce mortality or recurrence of PE compared with unfractionated heparin monotherapy in hemodynamically stable patients with pulmonary embolism?
In hemodynamically stable patients with pulmonary embolism, thrombolytic therapy does not significantly reduce death or recurrent PE but significantly increases the risk of major bleeding compared to unfractionated heparin.
Answers are grounded in this paper and cite their sources.
Supports withholding thrombolysis in stable PE; reinforces consensus of net harm from bleeding without significant efficacy gain.
Currently, thrombolytic therapy (TLT) for pulmonary embolism (PE) is recommended only for patients with high-risk PE. At the same time, in real practice, TLT is often performed in hemodynamically stable patients. The main contradiction arises due to the different risk-benefit ratio of TLT in comparison with anticoagulant monotherapy. Aim. To assess the benefits of TLT, compared with unfractionated heparin (UFH) monotherapy, in hemodynamically stable patients with PE in reducing mortality, recurrence of PE and risk of bleeding. Material and methods. Randomized controlled trials were searched in PubMed, Embase, and Cochrane Library databases. Of the 3050 publications found, 100 papers were selected for a detailed study. As a result of detailed analysis, 7 randomized clinical trials (n=1611) remained according to established criteria. Results. TLT in hemodynamically stable patients with PE, in comparison with UFH, showed a tendency to decrease in the inhospital death rate: 2,39% vs 3,68 (odds ratio (OR): 0,73; 95% confidence interval (СI): 0,34-1,57), and a decrease in the composite endpoint (death and/or recurrent PE): 3,14% vs 5,15% (OR: 0,61; CI: 0,37-1,01). There was a significant increase in the number of major bleeding: 8,81% vs 2,70% (OR: 3,35; 95% CI: 2,06-5,45). TLT in hemodynamically stable patients with PE to a greater extent can reduce the pulmonary blood pressure, perfusion defects according to lung scintigraphy, as well as the need for therapy intensification. However, the heterogeneity of studies and the small number of participants require caution when interpreting their results. Conclusion. TLT in patients with PE and stable hemodynamics tends to reduce mortality and/or recurrence of PE, but increases the incidence of major bleeding. Further studies need to determine the phenotypes of hemodynamically stable patients with PE who would benefit from TLT.
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Черепанова et al. (2022) conducted a meta-analysis in Pulmonary embolism (n=1,611). Thrombolytic therapy vs. Unfractionated heparin was evaluated on Composite endpoint (death and/or recurrent PE) (OR 0.61, 95% CI 0.37-1.01). Thrombolytic therapy in hemodynamically stable pulmonary embolism tended to reduce death or recurrent PE (OR 0.61; 95% CI 0.37-1.01) but significantly increased major bleeding (OR 3.35).
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