Safe‐Dose Thrombolysis Plus Rivaroxaban for Moderate and Severe Pulmonary Embolism: Drip, Drug, and Discharge

Abstract

Background Thrombolysis, though very effective, has not been embraced as routine therapy for symptomatic pulmonary embolism (PE) except in very severe cases. Rivaroxaban recently has been approved for the treatment of venous thromboembolism (VTE). There are no data on the combined use of thrombolysis and rivaroxaban in PE. Hypothesis “Safe dose” thrombolysis (SDT) plus new oral anticoagulants are expected to become an appealing, safe and effective approach in the treatment of moderate and severe PE in the near future, thereby drastically reducing hospitalization time. Methods Over a 12‐month period, 98 consecutive patients with symptomatic PE were treated by a combination of SDT and rivaroxaban. The SDT was started in parallel with unfractionated heparin and given in 2 hours. Heparin was given for a total of 24 hours and rivaroxaban started at 15 or 20 mg daily 2 hours after termination of heparin infusion. Results There was no bleeding due to SDT. Recurrent VTE occurred in 3 patients who had been switched to warfarin. No patient on rivaroxaban developed VTE. Two patients died of cancer at a mean follow‐up of 12 ± 2 months. The pulmonary artery systolic pressure dropped from 52.8 ± 3.9 mm Hg before to 32 ± 4.4 mm Hg within 36 hours of SDT (P < 0.001). The duration of hospitalization for patients presenting primarily for PE was 1.9 ± 0.2 days. Conclusions “Safe dose” thrombolysis plus rivaroxaban is highly safe and effective in the treatment of moderate and severe PE, leading to favorable early and intermediate‐term outcomes and early discharge.

Low‐dose systemic thrombolytic therapy for treatment of submassive pulmonary embolism: Clinical efficacy but attendant hemorrhagic risks

“…Non‐invasive “low‐dose” systemic TT (IV Alteplase 50 mg) has been advocated, based on the hypothesis that since the totality of venous return and right heart output bathes the pulmonary circulation, lower dosage and avoidance of “invasive” vascular access can achieve thrombolytic efficacy with lesser bleeding. This approach has been reported to achieve excellent clinical outcome with a striking elimination of major bleeding complications …”

“…“Invasive” catheter‐directed lytic (CDL) intervention (direct pulmonary artery infusion of Alteplase 10‐23 mg) appears clinically beneficial and is reported to have largely eliminated ICH, but is still associated with 10% major bleeding rates . Non‐invasive “low‐dose” systemic TT (Alteplase 50 mg IV) has been utilized in a small cohort and is reported to achieve excellent clinical outcome with a striking absence of bleeding …”

Alteplase for the Treatment of Pulmonary Embolism

“…Of note, there were no documented occurrences of intracranial hemorrhage in any group receiving fibrinolytic therapy. Reduced dose rt-PA was used in 98 patients who were then transitioned to rivaroxaban therapy 24 hr after rt-PA administration, and no increase in bleeding and reductions in pulmonary pressures were found (Sharifi, Bay, Schwartz, & Skrocki, 2014 …”

How New Approaches to the Treatment of Pulmonary Embolism Affect the Outcome of the Disease?

“…Данные в отношении применения НОАК при этих клинических ситуациях ограничены несколькими неболь-шими зарубежными и российскими исследованиями, которые скорее могут служить основанием для проведе-ния в дальнейшем крупных РКИ [38,39]. бологов России, стандартное лечение эпизода острой ТЭЛА (вопрос о показаниях и проведении тромболити-ческой терапии при остром эпизоде ТЭЛА не обсуждает-ся, так как выходит за рамки данной статьи) включает в себя назначение парентеральных антикоагулянтов (НФГ, НМГ или фондапаринукса) на 5-10 дней.…”