Pulmonary Embolism: Long‐term Follow‐up after Treatment with Full‐dose Heparin, Streptokinase or Embolectomy

Abstract

ABSTRACT. Lund, O, Nielsen, TT, Rønne, K, Schifter S (Departments of Thoracic and Cardiovascular Surgery, Cardiology, Respiratory Diseases, and Clinical Physiology and Nuclear Medicine, Aarhus University Hospital, Aarhus, Denmark). Pulmonary Embolism: Long‐term follow‐up after treatment with full‐dose heparin, streptokinase or embolectomy. Acta Med Scand 1987; 221:61–71. The study comprises 74 patients alive 30 days after the start of treatment of pulmonary embolism with heparin (n=32), streptokinase (n=22) or embolectomy (n=20). The cumulative 5‐year survival was 100% in the embolectomy group, compared to 75±7% (SE) in the medically treated patients (p<0.05). Cancer caused 78% of the late deaths. At follow‐up 0.5–8.7 years after treatment the treatment groups were indistinguishable as regards right‐sided heart catheterization data, pulmonary artery rest‐obstruction, right ventricular diameter and wall thickness, ventilatory function and ECG changes. The embolectomized patients were in a more favourable NYHA classification level than the medically treated. Chronic pulmonary artery hypertension was found in 75 % of patients with ≤3 anamnestic recurrent embolic episodes before diagnosis compared to 8 % of patients with ≥2 recurrent episodes (p<0.001). Patients with irreversible cardiocirculatory shock before embolectomy all had abnormal pulmonary vascular resistance (>1.5 mmHg/1/min), depressed ventilatory function and more than 25% reduced pulmonary perfusion at follow‐up. The major prognostic factors thus were cancer, the number of recurrent episodes and the degree of cardiocirculatory affection in the acute event. Although the embolectomized patients were the most affected initially, they had a good prognosis. This led us to extend our indications for embolectomy to include all patients with central emboli, irrespective of the degree of cardiocirculatory impairment.

Incidence of arterial cardiovascular events after venous thromboembolism: a systematic review and a meta-analysis

“…Three hundred and eight papers were excluded: 116 reported a follow-up shorter than 6 months, 190 did not provide data on cardiovascular events, and two were duplicate publications. Overall, 17 studies [11][12][13][14][23][24][25][26][27][28][29][30][31][32][33][34][35] were identified that reported the incidence of arterial cardiovascular events over the long term after VTE.…”

“…Seventeen studies reported data on the long-term incidence of arterial cardiovascular events (55 937 patients, median followup of 38 months, range 6-240 months); five were RCTs [22][23][24][25][26] and 12 were cohort studies [12][13][14][15][27][28][29][30][31][32][33][34]. The weighted mean incidence of arterial cardiovascular events was 0.74% per patient-year (95% CI 0.59-0.89; I 2 = 95%) ( Table 1).…”

Diagnostic Evaluation and Management of Chronic Thromboembolic Pulmonary Hypertension: A Clinical Practice Guideline

“…While thrombolytic therapy is associated with early resolution of clots and improved RV function compared with heparin alone (38), the effect of thrombolysis on the subsequent risk of persistent PH remains uncertain. Observational studies (15,39) have suggested that the treatment received during the acute phase of PE had no significant effects on the long-term pulmonary hemodynamics. In contrast, one small study (40) reported that patients assessed seven years after randomization to thrombolysis (n=12) versus control heparin (n=11) in the Urokinase PE (41) and Urokinase/streptokinase PE (42) trials, had improved pulmonary hemodynamic parameters at rest and during exercise, and experienced less functional impairment.…”

Chronic Thromboembolic Pulmonary Hypertension

“…Thrombolytics are frequently used to treat acute pulmonary emboli. The rapid and complete recanalization of the pulmonary arteries may decrease the subsequent development of CTEPH [33]. 23 of 40 patients who had angiographically proven pulmonary embolism and who had initially been randomized to an IV infusion of heparin (n = 11) or a thrombolytic agent (urokinase or streptokinase, n = 12) were restudied after a mean follow-up of 7.4 years to measure the right-sided pressures at rest and after supine bicycle ergometry exercise.…”