Acute intermediate-risk pulmonary embolism: is systemic thrombolytic therapy indicated?

Tromboembolismo pulmonar agudo de riesgo intermedio: ¿está indicada la trombólisis sistémica?

Introduction: pulmonary  embolism (PE) can be classified into low, intermediate,  and high-risk,  based on the patient characteristics and symptoms. Intermediate-risk  PE, formerly known  as submassive PE, poses the greatest challenge to clinicians, as indication for systemic thrombolytic therapy, remains controversial. Some authors and publications recommend its use, but the European Society of Cardiology (ESC) and the American Society of Hematology (ASH) do not. Materials and methods: a systematic literature review of 28 articles retrieved from search databases; of which, 7 met the inclusion criteria (6 systematic reviews/meta-analyses and a sequential analysis test on randomized trials) analyzing 39.879 PE patients. Results: among the assessed outcomes, major bleeding occurred in 8.1 to 9.24%, mortality in those who underwent systemic thrombolytic therapy was reported to be 2.1 to 2.2%; when comparing systemic thrombolytic therapy with anticoagulation therapy  for  preventing  hemodynamic  deterioration,  the  results  were  4.1%  and  14.1%  respectively.  Discussion and conclusions: the analyzed studies evidenced no impact on mortality or development of secondary pulmonary hypertension, in intermediate-risk PE patients receiving systemic thrombolytic therapy. However, results on its possible prevention of PE recurrence, while exceeding the risk of major bleeding (in nearly 10%), in most cases, are contradictory.

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