Thrombolysis for acute intermediate-risk pulmonary embolism: A meta-analysis

Gao, Guangyuan; Yang, Ping; Liu, Miao; Ding, Mei; Liu, Guohui; Tong, Yaliang; Yang, Chunyan; Meng, F.

doi:10.1016/j.thromres.2015.09.012

Cited by 25 publications

(14 citation statements)

References 24 publications

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“…The net benefit of thrombolytic strategies in the management of intermediate risk PE continues to be an area of active debate. Based on the results of our meta-analysis, we agree with other authors that the risk of bleeding is higher in patients who receive thrombolysis [30][31][32][33][34][35][36][37].…”

Section: Contrast With the Literaturesupporting

confidence: 91%

“…The PEITHO trial, the largest study that has included patients with intermediate risk PE, showed a clear advantage of thrombolysis in hemodynamic status and need of life-sustaining measures, yet no difference in 30-day mortality was found [27]. Although other metaanalysis have reported an improvement in mortality in the intervention group [32,35], we believe these results are driven by the composite primary outcome of the PEITHO trial, which includes early death and hemodynamic decompensation; this observation was also made by another group of authors [36]. A most recent analysis of multiple systematic reviews also reported a reduction in mortality secondary to thrombolysis, but recognizes that results are inconsistent, the large use of antinomies, and the questionable quality of some of the studies included [38].…”

Section: Contrast With the Literaturementioning

confidence: 99%

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The net benefit of thrombolysis in the management of intermediate risk pulmonary embolism: Systematic review and meta‐analysis

Alcedo

García‐Perdomo

Rojas‐Hernandez

2020

eJHaem

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Background Benefit of thrombolytic therapy in patients with massive pulmonary embolism (PE) is evident. However, evidence supporting benefit in clinical outcomes of this approach in intermediate risk PE is lacking. Objective To determine the impact of thrombolysis on overall survival in intermediate risk PE patients. Methods We searched in MEDLINE (OVID), EMBASE, LILACS, and the Cochrane Central Register of Controlled Trials (CENTRAL) from present day. We also searched in other databases and unpublished literature. We included clinical trials without language restrictions. The risk of bias was evaluated with the Cochrane Collaboration's tool. The primary outcome was overall survival. Secondary outcomes were adverse events, including major bleeding, and all‐cause mortality. The measure of the effect was the risk ratio with a 95% confidence interval (CI). Results We included 11 studies in the qualitative and quantitative analysis, with a total of 1855 patients. Risk of bias was variable among the study items. There were no results reported about overall survival in any of the studies. The risk ratio (RR) for all‐cause mortality was 0.68 95% CI (0.40 to 1.16). The RR of overall bleeding, major bleeding and stroke were 2.72 95% CI (1.58 to 4.69), 2.17 95% CI (1.03 to 4.55), and 2.22 95% CI (0.17 to 28.73), respectively. Additionally, the RR for recurrent PE was 0.56 95% CI (0.23 to 1.37). Conclusions In patients with intermediate risk PE, the risk of bleeding is higher when thrombolysis is used. There was no significant difference between thrombolysis and anticoagulation in recurrence of PE, stroke, and all‐cause mortality.

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Section: Contrast With the Literaturesupporting

confidence: 91%

Section: Contrast With the Literaturementioning

confidence: 99%

The net benefit of thrombolysis in the management of intermediate risk pulmonary embolism: Systematic review and meta‐analysis

Alcedo

García‐Perdomo

Rojas‐Hernandez

2020

eJHaem

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“…52 In the MAPPET 3 study, which assessed 256 patients with PH or RV failure, a reduction in HI from 24 to 10% was observed in the arm in which rtPA was used, but there was an increase in major bleeding from 0.8 to 3.6%. 10 The PEITHO study assessed 1,006 patients with submassive PTE (RV dilatation and dysfunction) and although SFT corrected HI from 5 to 1.6%, there was an increase in major bleeding, from 2.4 to 11.5%, and in CNS bleeding from 0.2 to 2%.…”

Section: Patients With Submassive Pte (Moderate Risk)mentioning

confidence: 99%

Terapia fibrinolítica sistêmica no tromboembolismo pulmonar

Ceresetto

Marques

2017

J. vasc. bras.

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Pulmonary thromboembolism remains a major therapeutic challenge for specialists and, despite investment and the consequent developments in diagnosis, prophylaxis, and treatment, the condition is still the leading cause of avoidable deaths in hospital settings. There is still great uncertainty with relation to the profile of patients who will actually benefit from systemic fibrinolytic treatment, without being exposed to serious risk of bleeding. There are tools that can help to identify patients who will benefit, including risk stratification and estimation of the prognosis of the event, with clinical scores for right ventricular failure, markers of right ventricular dysfunction and dilatation, and thrombotic mass assessment, whether alone or in combination. The only points of consensus with relation to fibrinolytic therapy for treatment of pulmonary thromboembolism are as follows: it should not be routinely indicated, none of the scores or markers alone should be used to justify its use, and patients with hemodynamic instability are the most likely to benefit. Furthermore, each case should be evaluated for risk of bleeding, especially central nervous system bleeding.Keywords: fibrinolytics; pulmonary embolism; hemorrhage. ResumoO tromboembolismo pulmonar permanece como um grande desafio terapêutico para os médicos especialistas, pois, apesar de todo investimento e desenvolvimento em seu diagnóstico, profilaxia e tratamento, essa condição continua sendo a principal causa de morte evitável em ambiente hospitalar. Ainda restam muitas dúvidas em relação a qual perfil de paciente vai se beneficiar de fato da terapia fibrinolítica sistêmica, sem ficar exposto a um grande risco de sangramento. A estratificação de risco e a avaliação do prognóstico do evento, através de escores clínicos de insuficiência ventricular direita, marcadores de dilatação e disfunção do ventrículo direito e avaliação da massa trombótica, associados ou de forma isolada, são ferramentas que podem auxiliar na identificação do paciente que irá se beneficiar dessa terapia. Os únicos consensos em relação à terapia fibrinolítica no tratamento do tromboembolismo pulmonar são: não deve ser indicada de forma rotineira; nenhum dos escores ou marcadores, isoladamente, devem justificar seu uso; e os pacientes com instabilidade hemodinâmica são os mais beneficiados. Além disto, deve-se avaliar cada caso em relação ao risco de sangramento, especialmente no sistema nervoso central.Palavras-chave: fibrinolíticos; embolia pulmonar; hemorragia.

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“…Furthermore, thrombolytic therapy was associated with a lower incidence of recurrent PE [RR, 0.33; 95% CI, 0.15–0.73; 0.73%;0.73% (6/826) versus 2.72% (23/846)]. The authors concluded that, compared with anticoagulation thrombolytic therapy in patients with intermediate-risk PE, there is a lower all-cause mortality and recurrent PE risk despite increased major and minor bleeding [Gao et al . 2015].…”

Section: Other Studiesmentioning

confidence: 99%

Potential role of systemic thrombolysis in acute submassive intermediate risk pulmonary embolism: review and future perspectives

Teleb

Porres‐Aguilar

Anaya‐Ayala

et al. 2016

Therapeutic Advances in Cardiovascular Disease

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Submassive (intermediate risk) pulmonary embolism (PE) continues to be a significantly morbid disease process that remains unrecognized, inadequately risk stratified and suboptimally treated. Appropriate early clinical and imaging-based risk stratification represents the cornerstone for adequate therapeutic decision making, particularly for the selection of candidates who may benefit the most from systemic thrombolysis. The relevance of estimating clinical prognostic scores, in combination with imaging data, for accurate assessment of right ventricular function and laboratory biomarkers, indicative of myocardial injury for identification of normotensive patients at intermediate risk for an adverse short-term outcome are emphasized in this review. Recent clinical trials have demonstrated improvement in hemodynamics and mortality with the use of systemic thrombolysis among intermediate risk patients; however, it came at the cost of a significantly increased risk of major bleeding. Catheter-based therapies have garnered considerable clinical interest in recent years; of particular note is the ultrasound accelerated catheter-directed thrombolysis which has emerged as a novel and attractive alternative therapeutic modality with an increasing number of single center studies and ongoing randomized trials. Our review focuses on the major trials and studies involved in submassive PE in the recent literature including the role of thrombolytic therapy. We include major trials with reasonable sample size and extensive review of the potential side effects, such as major bleeding.

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Thrombolysis for acute intermediate-risk pulmonary embolism: A meta-analysis

Cited by 25 publications

References 24 publications

The net benefit of thrombolysis in the management of intermediate risk pulmonary embolism: Systematic review and meta‐analysis

The net benefit of thrombolysis in the management of intermediate risk pulmonary embolism: Systematic review and meta‐analysis

Terapia fibrinolítica sistêmica no tromboembolismo pulmonar

Potential role of systemic thrombolysis in acute submassive intermediate risk pulmonary embolism: review and future perspectives

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