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)
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