Review: In pulmonary embolism, thrombolytic therapy reduces all-cause mortality but increases major bleeding

2014 ◽  
Vol 161 (6) ◽  
pp. JC9
Author(s):  
Elie A. Akl ◽  
Gordon H. Guyatt
Keyword(s):  
Pulmonary Embolism ◽  
Thrombolytic Therapy ◽  
Major Bleeding ◽  
All Cause Mortality

Clinical characteristics and 3-month outcomes in cancer patients with incidental versus clinically-suspected and confirmed pulmonary embolism

2020 ◽  
pp. 2002723
Author(s):  
Marisa Peris ◽  
Juan J. López-Nuñez ◽  
Ana Maestre ◽  
David Jimenez ◽  
Alfonso Muriel ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Mortality Rate ◽  
Cancer Patients ◽  
Major Bleeding ◽  
Management Strategies ◽  
Multivariable Analysis ◽  
Heparin Therapy ◽  
Incidental Pulmonary Embolism ◽  
All Cause Mortality ◽  
Related Mortality

BackgroundCurrent guidelines suggest treating cancer patients with incidental pulmonary embolism (PE) similar to those with clinically-suspected and confirmed PE. However, the natural history of these presentations has not been thoroughly compared.MethodsWe used the data from the RIETE registry to compare the 3-month outcomes in patients with active cancer and incidental PE versus those with clinically-suspected and confirmed PE. The primary outcome was 90-day all-cause mortality. Secondary outcomes were PE-related mortality, symptomatic PE recurrences and major bleeding.ResultsFrom July 2012 to January 2019, 946 cancer patients with incidental asymptomatic PE and 2274 with clinically-suspected and confirmed PE were enrolled. Most patients (95% versus 90%) received low-molecular-weight heparin therapy. During the first 90 days, 598 patients died, including 42 from PE. Patients with incidental PE had a lower all-cause mortality rate than those with suspected and confirmed PE (11% versus 22%; odds ratio [OR]: 0.43; 95%CI: 0.34–0.54). Results were consistent for PE-related mortality (0.3% versus 1.7%; OR: 0.18; 95% CI: 0.06–0.59). Multivariable analysis confirmed that patients with incidental PE were at lower risk to die (adjusted OR: 0.43; 95%CI: 0.34–0.56). Overall, 29 patients (0.9%) developed symptomatic PE recurrences, and 122 (3.8%) had major bleeding. There were no significant differences in PE recurrences (OR: 0.62; 95%CI: 0.25–1.54) or major bleeding (OR: 0.78; 95%CI: 0.51–1.18).ConclusionsCancer patients with incidental PE had a lower mortality rate than those with clinically-suspected and confirmed PE. Further studies are required to validate these findings, and to explore optimal management strategies in these patients.

scholarly journals 2163Predicting in-hospital major bleeding in pulmonary embolism patients treated with systemic thrombolytic therapy

2018 ◽  
Vol 39 (suppl_1) ◽  
Author(s):  
K.-P Kresoja ◽  
N Meneveau ◽  
D Jimenez ◽  
O Sanchez ◽  
C Becattini ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Thrombolytic Therapy ◽  
Major Bleeding ◽  
Systemic Thrombolytic Therapy

scholarly journals Management appropriateness and outcomes of patients with acute pulmonary embolism

2018 ◽  
Vol 51 (5) ◽  
pp. 1800445 ◽  
Author(s):  
David Jiménez ◽  
Behnood Bikdeli ◽  
Deisy Barrios ◽  
Raquel Morillo ◽  
Rosa Nieto ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Major Bleeding ◽  
Acute Pulmonary Embolism ◽  
External Validation ◽  
Vena Cava ◽  
Vena Cava Filters ◽  
All Cause Mortality ◽  
The Impact ◽  
Related Mortality

The impact of adherence to published guidelines on the outcomes of patients with acute pulmonary embolism (PE) has not been well defined by previous studies.In this prospective cohort study of patients admitted to a respiratory department (n=2096), we evaluated whether patients with PE had better outcomes if they were acutely managed according to international guidelines. Outcomes consisted of all-cause mortality, PE-related mortality, recurrent venous thromboembolism (VTE) and major bleeding events during the first month of follow-up after diagnosis.Overall, 408 patients (19% (95% CI 18–21%)) did not receive guideline-adherent PE management. Patients receiving non-adherent management were significantly more likely to experience all-cause mortality (adjusted odds ratio (OR) 2.39 (95% CI 1.57–3.61) or PE-related mortality (adjusted OR 5.02 (95% CI 2.42–10.42); p<0.001) during follow-up. Non-adherent management was also a significant independent predictor of recurrent VTE (OR 2.19 (95% CI 1.11–4.32); p=0.03) and major bleeding (OR 2.65 (95% CI 1.66–4.24); p<0.001). An external validation cohort of 34 380 patients with PE from the RIETE registry confirmed these findings.PE management that does not adhere to guidelines for indications related to anticoagulation, thrombolytics and inferior vena cava filters is associated with worse patient outcomes.

scholarly journals Right heart thrombi in pulmonary embolism

2016 ◽  
Vol 48 (5) ◽  
pp. 1377-1385 ◽  
Author(s):  
Deisy Barrios ◽  
Vladimir Rosa-Salazar ◽  
David Jiménez ◽  
Raquel Morillo ◽  
Alfonso Muriel ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Major Bleeding ◽  
Prognostic Significance ◽  
Right Heart ◽  
Younger Age ◽  
Increased Risk ◽  
All Cause Mortality ◽  
Oxyhaemoglobin Saturation ◽  
Related Mortality

There is a lack of comprehensive data on the prevalence, predictors and prognostic significance of right heart thrombi (RHT) in pulmonary embolism.In this study of patients with pulmonary embolism from the Registro Informatizado de la Enfermedad TromboEmbólica (RIETE) registry, we assessed the prevalence and predictors of RHT, and the association between the presence of RHT and the outcomes of all-cause mortality, pulmonary embolism-related mortality, recurrences, and major bleeding through 30 days after initiation of pulmonary embolism treatment.Of 12 441 patients with pulmonary embolism and baseline echocardiographic data, 2.6% had RHT. The following increased the risk of RHT: younger age, previous bleeding, congestive heart failure, cancer, syncope, systolic blood pressure <100 mmHg, and arterial oxyhaemoglobin saturation <90%. Patients with RHT were significantly more likely to die from any cause (adjusted OR 2.50 (95% CI 1.62–3.84); p<0.001) and from pulmonary embolism (adjusted OR 4.29 (95% CI 2.45–7.48); p<0.001) during follow-up. RHT was associated with an increased risk of recurrence during follow-up (1.8% versus 0.7%; p=0.04). Major bleeding was similar in patients with and without RHT.In patients presenting with pulmonary embolism, RHT is relatively infrequent. Patients with RHT had a worse outcome when compared with those without RHT.

scholarly journals The Net Clinical Benefit of Thrombolysis in the Management of Submassive Pulmonary Embolism: Systematic Review and Meta-Analysis

Blood ◽  
2019 ◽  
Vol 134 (Supplement_1) ◽  
pp. 2440-2440
Author(s):  
Pedro Alcedo ◽  
Cristhiam Mauricio Rojas Hernandez ◽  
Herney Andres Garcia Perdomo
Keyword(s):  
Overall Survival ◽  
Pulmonary Embolism ◽  
Thrombolytic Therapy ◽  
Meta Analysis ◽  
Risk Of Bias ◽  
Cochrane Central Register ◽  
Right Ventricular Strain ◽  
Significant Difference ◽  
All Cause Mortality ◽  
The Impact

Background: Benefit of thrombolytic therapy in patients with massive pulmonary embolism (PE) has been proven. Evidence supporting benefit in clinical outcomes of this approach in the subgroup of patients with submassive PE is lacking. Objective: The primary objective was to determine the impact of thrombolysis on overall survival in patients with submassive PE. Secondary outcomes included bleeding, thrombotic complications, improvement on parameters of right ventricular strain and all cause-mortality. Methods: A search strategy was conducted in MEDLINE (OVID), EMBASE, LILACS and the Cochrane Central Register of Controlled Trials (CENTRAL) from inception to nowadays. Search was also conducted in other databases and unpublished literature. Clinical trials were included without language restrictions. The risk of bias was evaluated with the Cochrane Collaboration's tool. We performed a meta-analysis with a fixed effect model according to the heterogeneity. PROSPERO registration number is CRD42019128229. Results: Twelve studies were included in the qualitative and quantitative analysis. 2,564 patients were found among the twelve studies. Risk of bias was assessed mostly as low or unclear risk among the study items. The risk ratio (RR) for all-cause mortality was 1.00 95% CI (0.77 to1.30). The RR of total bleeding and major bleeding were 2.72 95% CI (1.58 to4.69) and 2.17 95% CI (1.03 to4.55), respectively, finding higher risk in thrombolytic therapy. For stroke the RR was 2.22 95% CI (0.17 to28.73), and for recurrent PE the RR was 0.56 95% CI (0.23 to1.37), finding no differences regarding these outcomes. Unfortunately, there were no results reported about overall survival in any of the studies. Conclusion: In patients with submassive PE, the risk of bleeding is higher when thrombolysis is used. There is no significant difference between thrombolysis and anticoagulation in recurrence of PE, stroke, and all-cause mortality Figure Disclosures No relevant conflicts of interest to declare.

P5715Trends in indications and outcome in thrombolytic therapy: a retrospective single center study

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
M M Engelen ◽  
T Vanassche ◽  
C Vandenbriele ◽  
P Sinnaeve ◽  
I Fourneau ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Peripheral Arterial Disease ◽  
Thrombolytic Therapy ◽  
Major Bleeding ◽  
Survival Rates ◽  
Arterial Disease ◽  
Coronary Syndrome ◽  
Single Center Study ◽  
Short Term Mortality ◽  
Peripheral Arterial

Abstract Background Thrombolytic therapy is used as a lifesaving treatment for a broad range of acute thrombotic events. The role of thrombolysis for its various indications has rapidly evolved. Purpose To provide a contemporary overview of current indications and outcome of thrombolytic therapy in clinical practice. Methods This retrospective single-center study analyzed indications, complications and short-term mortality of systemic thrombolytic therapy between 2010 and 2016 in a university hospital, totaling 763 cases. Major bleedings were defined using criteria published by the International Society on Thrombosis and Haemostasis (ISTH). Results Thrombolytic drugs were mostly used for ischemic strokes (66.6%) and peripheral arterial disease (16.9%). Acute coronary syndrome only represented a minority of cases (in this PCI-center). Overall seven- and thirty-day-mortality were 7.3% and 12.0%, respectively. Major bleeding occurred in 8.3% of patients and was fatal in 0.9% of all patients. Both major bleeding and mortality differed by the indication for thrombolysis. Thrombolytic therapy for pulmonary embolism and peripheral arterial disease were associated with the highest rates of major bleeding, 28.6% and 23.3% respectively. Short-term mortality was highest in patients receiving thrombolysis for pulmonary embolism. Predictors for major bleeding included use of antiplatelet and anticoagulation drugs prior to thrombolysis. Major bleedings, age and concomitant anticoagulation were associated with lower survival rates. Indications in absolute numbers – 2010 – – 2011 – – 2012 – – 2013 – – 2014 – – 2015 – – 2016 – Ischemic Stroke 56 63 66 57 96 88 82 Peripheral Arterial Disease 21 23 21 28 14 16 6 Pulmonary Embolism 4 9 10 10 5 8 8 Deep Vein Thrombosis 2 1 2 0 2 3 3 Acute Coronary Syndrome 0 1 0 1 0 0 0 Mechanical Heart Valve Thrombosis 1 3 3 1 2 7 1 Other 5 8 3 10 2 5 6 TOTAL 89 108 105 107 121 127 106 Mortality and major bleeding in % Conclusion The use of thrombolytic therapy has evolved, with stroke now being the most frequent indication. Mortality and bleeding rates are significant and vary considerably per indication. Major bleedings, age and maintenance anticoagulant therapy were risk factors associated with lower survival rates, but the underlying disease and patient population seem to play a major role in survival as well.

P6459Comparison of the new BLLADS score with other scores for the prediction of major bleeding in patients with acute pulmonary embolism

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
B Subotic ◽  
B Dzudovic ◽  
N Novicic ◽  
J Matijasevic ◽  
S Salinger ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Thrombolytic Therapy ◽  
Risk Score ◽  
Major Bleeding ◽  
Acute Pulmonary Embolism ◽  
Predictive Power ◽  
Laboratory Data ◽  
Bleeding Risk ◽  
Cox Regression Analysis ◽  
Increased Risk

Abstract Background Hemorrhagic complications are a major obstacle for aggressive antithrombotic therapy in patients with acute pulmonary embolism (PE). Objectives We aimed to develop a simple risk score for predicting major bleeding (MB) in patients with acute PE using medical history and laboratory data at admission, including the potential influence of thrombolytic therapy, and to compare its predictive power to bleeding risk scores previously developed for patients with atrial fibrillation or venous thromboembolism. Methods A total of 630 consecutive patients treated for PE in six Serbian University hospitals were followed up for the occurrence of MB over a 90-day period after admission. A 6-component bleeding risk score was developed after Cox regression analysis of possible variables presented at admission. The use of thrombolytic therapy was also tested as a risk factor for bleeding and was integrated into the score. The ATRIA, HAS BLED, RIETE and VTE-BLEED scores were calculated for each patient at baseline and the predictive performances were compared with new score using c-statistics. Results MB occurred in 61 (9.7%) patients during the 90-day follow-up, with no increased risk of all-cause mortality (p=0.108). Six independent factors associated with MB were included in the final model (previous bleeding, leukocyte count ≥14x109/L, receipt of thrombolytic therapy, anemia, drugs associated with bleeding, and recent surgery; BLLADS). For the six- and five-variable models (without points for thrombolysis), C-indices were 0.774 (95% confidence interval [CI], 0.713–0.835, p<0.001) and 0.713 (95% CI, 0.639–0.788, p<0.001), respectively. The predictive power of the BLLADS score was found to be superior in comparison with other four scores: c-index 0.779 (95% CI 0.716–0.841, p<0.001), 0,614 (95% CI 0.535–0.692, p=0.005), 0.591 (95% CI 0.518–0.664, p=0.025), 0.589 (95% CI 0.518–0.659, p=0.029), 0.586 (95% CI 0.508–0.664, p=0.035), for continuous BLLADS, RIETE, VTE-BLEED, ATRIA and HAS BLED scores, respectively. Conclusion A simple six-variable score including the use of thrombolysis was developed with sufficient discriminative capacity comparing to current available scores for the prediction of 90-day MB for non-selected PE patients.

P3852Twenty-eight-year temporal trends of treatment strategy and short-term outcomes in patients with high-risk pulmonary embolism: impact of ESC guidelines changes

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
Y Hosokawa ◽  
T Yamamoyo ◽  
A Tanida ◽  
J Matsuda ◽  
H Sangen ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
High Risk ◽  
Thrombolytic Therapy ◽  
Major Bleeding ◽  
Treatment Strategy ◽  
Temporal Trends ◽  
Ivc Filter ◽  
Short Term ◽  
Esc Guidelines ◽  
Filter Insertion

Abstract Background Thrombolysis has been recommended for high-risk pulmonary embolism (PE) in ESC guidelines, used as a reference in Japan. Recently, indication of thrombolysis for acute PE has been limited with recent guideline revision. Little is known regarding trends of treatment strategy and mortality in high-risk PE patients. Purpose To clarify temporal trends of treatment strategy and short-term outcomes in high-risk PE patients. Methods A retrospective analysis of therapeutic interventions and short-term outcomes was performed for 52 consecutive high-risk PE patients including cardiac arrest. According to timing of ESC guidelines update (2000, 2008 and 2014), patients were divided into four time periods: 1992 to 2000, 2001 to 2008, 2009 to 2014, and 2015 to 2018. Results Mean age and proportion of male were not different over the period. Nosocomial case decreased from 100% to 25% (p<0.01). Postoperative cases (relative contraindication for thrombolysis) included 43% of all patients. Cardiac arrest and VA-ECMO use were 42% and 21% of all patients. Any thrombolytic therapy including catheter-directed intervention showed a non-significant decrease trend (92%-87%-71%-44%, p=0.067). Temporary or retrieval IVC filter insertion showed a significant downward trend (36%-80%-54%-22%, p=0.025). The entire study 30-day mortality was 23%. There was no significant difference in 30-day mortality over the periods (14%-27%-14%-44%, p=0.303). However, major bleeding decreased significantly (71%-40%-7%-22%, p=0.004) (Table). Table 1 1992–2000 (n=14) 2001–2008 (n=15) 2009–2014 (n=14) 2015–2018 (n=9) p Age (years) 54±12 59±17 64±13 65±16 0.224 Male 29% 13% 29% 44% 0.269 Any thrombolytic therapy 92% 87% 71% 44% 0.067 Catheter-directed therapy 86% 87% 71% 0% <0.01   with thrombolytics (92%) (83%) (90%)   without thromboloytics (8%) (17%) (10%) Only intravenous thrombolysis 8% 7% 7% 44% 0.038 Temporary/retrieval IVC filter 36% 80% 54% 22% 0.025 ICU stay (days) 15±14 10±18 5±4 8±8 0.206 30-day mortality 14% 27% 14% 44% 0.303 Major bleeding 71% 40% 7% 22% 0.004 Conclusion The temporal analysis identified a decreased trend in any thrombolytic therapy and IVC filter insertion in high-risk PE. The study also found a decreasing trend in major bleeding.

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