It is clear that patients with stable PE should not be treated with thrombolytics (ACCP guidelines). However, in those that are “unstable” it is less clear when to administer it. In a past small RCT in patients with submassive PE (defined as R heart dysfunction or pulmonary HTN) (abstract) anteplase+heparin (versus heparin) reduced clinical deterioration of PE patients, but not death or recurrent PE. In this retrospective cohort of over 15,000 patients, thrombolytics were given to only 2.4% of patients. Using propensity scoring, they found higher mortality in those given thrombolytics, but no difference in death in the high-propensity scorers with or without thrombolytics. Although this study was imperfect with residual confounding, it does suggest a few things: we are appropriately stingy in giving thrombolytics (<3%), the risk of bleeding is low (2%), the risk of death is high (10%), and it is still up to us to imperfectly determine which patients are “unstable” and will therefore more likely benefit from thrombolytics (abstract) (editorial)
Dr. Scheurer is a clinical hospitalist and the Medical Director of Quality and Safety at the Medical University of South Carolina in Charleston, South Carolina, and is Assistant Professor of Medicine. She is a graduate of the University of Tennessee College of Medicine, completed her residency at Duke University, and completed her Masters in Clinical Research at the Medical University of South Carolina. She also serves as the Web Editor and Physician Advisor for the Society of Hospital Medicine.