Systematic review and meta-analysis for thrombolysis treatment in patients with acute submassive pulmonary embolism

Abstract

PurposeThe aim of this systematic review was to evaluate the efficacy and safety of thrombolytic treatment in patients with submassive pulmonary embolism (PE).MethodsAn electronic search was carried out based on the databases from MEDLINE, Embase, Science Citation Index (SCI), and the Cochrane Library. We included prospective, randomized, and clinical trials in thrombolysis with heparin alone in adults who had evidence of right ventricular dysfunction and normotension. The main endpoints consist of mortality, recurrent PE, and bleeding risk. The relative risk (RR) and the relevant 95% confidence intervals were determined by the dichotomous variable.ResultsOnly seven studies involving 594 patients met the inclusion criteria for further review. The cumulative effect of thrombolysis, compared with intravenous heparin, demonstrated no statistically significant difference in mortality (2.7% versus 4.3%; RR=0.64 [0.29–1.40]; P=0.27) or recurrent PE (2% versus 5%; RR=0.44 [0.19–1.05]; P=0.06). Thrombolytic therapy did not increase major hemorrhage compared with intravenous heparin (4.5% versus 3.3%; RR=1.16 [0.51–2.60]; P=0.73), but it was associated with an increased minor hemorrhage (41% versus 9%; RR=3.91 [1.46–10.48]; P=0.007).ConclusionCompared with heparin alone, neither mortality nor recurrent PE is reduced by thrombolysis in patients with submassive PE, and it does not reveal an increasing risk of major bleeding. In addition, thrombolysis also produces the increased risk of minor bleeding; however, no sufficient evidence verifies the thrombolytic benefit in this review, because the number of patients enrolled in the trials is limited. Therefore, a large, double-blind clinical trial is required to prove the outcomes of this meta-analysis.

A retrospective analysis of catheter-based thrombolytic therapy for acute submassive and massive pulmonary embolism

“…22 To date, this data has limited the expansion of systemic thrombolysis therapy beyond the highest risk patients. 23 By instituting lower doses and targeting the thrombolysis therapy to the pulmonary bed, CBT has the potential to offset the previously noted bleeding complications and provide clinical benefit. Of note, the efficacy of low-dose thrombolysis, which exhibits similar efficacy as higher-dose thrombolytics, has not been directly compared to a CBT strategy.…”

The role of thrombolytic therapy in pulmonary embolism

“…Thrombolysis also increased the risk of major bleeding in stable PE in the analysis done by Chatterjee et al 7 and in ours, but not in the analyses done by Cao et al 8 and Nakamura et al 5 Cao et al 8 did not include the PEITHO study (the largest study), 25 because the meta-analysis was done prior to the publication of the PEITHO study. Fewer patients were therefore included, which could have resulted in loss of power.…”

“…We chose to use fixed-effect models because there was low heterogeneity across the included studies. Furthermore, in our analysis of stable PE with RVD, the studies we included were not identical to the ones in the analyses done by Cao et al 8 and Nakamura et al 5 ( Table 2). We chose to include only studies in which RVD was clearly defined, in order to draw conclusions in this particular patient population.…”

“…Both Cao et al 8 and Nakamura et al 5 analyzed only studies of stable PE and concluded that thrombolysis failed to improve overall mortality or recurrent PE with similar risk of major bleeding. However, Marti et al 6 and Chatterjee et al 7 found a significant reduction in overall mortality with thrombolysis when all PE studies were combined, with increased risks of major hemorrhage and intracranial bleeding.…”

“…A number of meta-analyses were recently published but reached different conclusions. [5][6][7][8] The aim of this review is to provide evidence-based practice recommendations for the use of thrombolytic therapies in the treatment of PE with and without hemodynamic instability. In addition, we intend to determine the optimal regimen of thrombolytic therapy based on available data.…”