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Thrombolytic therapy and mortality in patients with acute pulmonary embolism
Standard treatment of acute pulmonary embolism (PE) consists of regimens involving anticoagulation therapy alone. Thrombolytic therapy (TT) may provide a mechanism for more rapid thrombus dissolution and improvement in pulmonary blood flow and may therefore offer benefit to certain patient groups, such as those presenting with features of cardiopulmonary compromise. However, previous studies have failed to demonstrate a clear mortality advantage for TT among patients presenting with acute PE, and data for the indications and benefit of TT in this setting are inconsistent. It remains unclear how these mixed reports have influenced the prevalence of TT in both academic and community hospital settings.
In order to deal with this knowledge gap Ibrahim and coworkers analysed a state-wide (Pennsylvania, USA) database involving 15 116 patients who had a primary diagnosis of PE. Patients with a prior diagnosis of major bleeding were excluded. Specifically, the prevalence of TT together with 30-day and in-hospital mortality, before and after propensity adjustment, were recorded.
Only 356 (2.4%) patients received TT. These patients were more likely to be younger (p<0.001), male (p = 0.01) and covered by medical insurance (p<0.001). Patients who did not receive TT were more likely to have diagnoses of lung disease, heart failure and/or cerebrovascular disease and less likely to have a history of ischaemic heart disease (p<0.02) and/or pulmonary vascular disease (p<0.02). Physical examination among patients receiving TT showed a higher incidence of tachycardia (>110 bpm), lower systolic blood pressure (<100 mm Hg), higher respiratory rate (<30/min), hypoxaemia (arterial oxygen saturation <90%), acidosis (pH<7.25), raised levels of troponin (⩾0.1 ng/ml) and/or higher pulmonary arterial pressure (>40 mm Hg); p<0.01 for each.
The overall 30-day mortality rate for patients receiving TT was 17.4% versus 8.6% for those who did not (OR = 2.2 (95% CI 1.7 to 3.0); p<0.001). However, when patients were divided into quintiles based …