Acute intermediate-risk pulmonary embolism: is systemic thrombolytic therapy indicated?
Tromboembolismo pulmonar agudo de riesgo intermedio: ¿está indicada la trombólisis sistémica?
Article Sidebar
PDF (Español (España))
FLIP
Main Article Content
Abstract
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.
Downloads
Article Details
References
Wendelboe AM, Raskob GE. Global Burden of Thrombosis, epidemiologic aspects. Cir Res. 2016;118(9):1340–1347. https://doi.org/10.1161/CIRCRESAHA.115.306841. DOI: https://doi.org/10.1161/CIRCRESAHA.115.306841
Gao GY, Yang P, Liu M, Ding M, Liu GH, Tong YL, et al. Thrombolysis for acute intermediate-risk pulmonary embolism: A meta-analysis. Thromb Res. 2015;136(5):932–937. https://doi.org/10.1016/j.thromres.2015.09.012. DOI: https://doi.org/10.1016/j.thromres.2015.09.012
Cifuentes Garzón AM, Galindo Rojas EF, Garzón Torres MX y Gómez Rodríguez LB. Utilidad de la escala de Wells para detección de tromboembolismo pulmonar [Tesis]. Bogotá: Universidad de Ciencias Aplicadas y Ambientales; 2020.
Dennis RJ, Rojas MX, Molina A, Roa J, Granados M, Londoño A, et al. Curso clínico y supervivencia en embolia pulmonar Resultados del registro multicéntrico colombiano (EMEPCO). Acta Med Colomb. 2008;33(3):111-116.
Turetz M, Sideris AT, Friedman OA, Triphathi N, Horowitz JM. Epidemiology, Pathophysiology, and Natural History of Pulmonary Embolism. Semin Intervent Radiol. 2018;35(2):92–98. https://doi.org/10.1055/s-0038-1642036. DOI: https://doi.org/10.1055/s-0038-1642036
Machanahalli Balakrishna A, Reddi V, Belford PM, Alvarez M, Jaber WA, Zhao DX, Vallabhajosyula S. Intermediate-Risk Pulmonary Embolism: A Review of Contemporary Diagnosis, Risk Stratification and Management. Medicina (Kaunas). 2022;58(9):1186. https://doi.org/10.3390/medicina580911866. DOI: https://doi.org/10.3390/medicina58091186
Kline JA, Nordenholz KE, Courtney DM, Kabrhel C, Jones AE, Rondina MT, et al. Treatment of submassive pulmonary embolism with tenecteplase or placebo: Cardiopulmonary outcomes at 3 months: Multicenter double-blind, placebo-controlled randomized trial. J Thromb Haemost. 2014;12(4):459–68. https://doi.org/10.1111/jth.12521. DOI: https://doi.org/10.1111/jth.12521
Konstantinides SV, Meyer G, Bueno H, Galié N, Gibbs JSR, Ageno W, et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European respiratory society (ERS). Eur Heart J. 2020;41(4):543–603. https://doi.org/10.1093/eurheartj/ehz405. DOI: https://doi.org/10.1093/eurheartj/ehz405
Alcedo PE, García‐Perdomo HA, Rojas‐Hernandez CM. The net benefit of thrombolysis in the management of intermediate risk pulmonary embolism: Systematic review and meta‐analysis. eJHaem. 2020;1(2):457–66. https://doi.org/10.1002/jha2.97. DOI: https://doi.org/10.1002/jha2.97
Seif MA. A systematic review for the role of systemic thrombolysis in intermediate-risk (submassive) pulmonary embolism. Qatar Med J. 2020;2019(2):80. doi: https://doi.org/10.5339/qmj.2019.qccc.80. DOI: https://doi.org/10.5339/qmj.2019.qccc.80
Freund Y, Cohen-Aubart F, Bloom B. Acute Pulmonary Embolism: A Review. JAMA. 2022;328(13):1336–1345. https://doi.org/10.1001/jama.2022.16815. DOI: https://doi.org/10.1001/jama.2022.16815
Nachman D, Pollack A, Herzog E. Epidemiology, pathophysiology and predisposing factors of pulmonary embolism and deep vein thrombosis. In: Herzog E (eds). Pulmonary Embolism. Springer, Cham; 2021. p.92–98. https://doi.org/10.1007/978-3-030-87090-4. DOI: https://doi.org/10.1007/978-3-030-87090-4_2
Piazza, Gregory. Advanced management of intermediate-and High-Risk pulmonary embolism. JACC Focus seminar. J Am Coll Cardiol. 2020;76(18):2117-2127. https://doi.org/10.1016/j.jacc.2020.05.028. DOI: https://doi.org/10.1016/j.jacc.2020.05.028
Pillus D, Bruno E, Farcy D, Vilke GM, Childers R. Systematic Review: The Role of Thrombolysis in Intermediate-Risk Pulmonary Embolism. J Emerg Med. 2019;57(4):517–522. https://doi.org/10.1016/j.jemermed.2019.06.014. DOI: https://doi.org/10.1016/j.jemermed.2019.06.014
Davies RE, Foy A, Gilchrist I. Does thrombolysis reduce mortality in patients with intermediate risk pulmonary embolism? a trial sequential analysis. J Am Coll Cardiol. 2017;69(11_Supplement):1897. https://doi.org/10.1016/S0735-1097(17)35286-5. DOI: https://doi.org/10.1016/S0735-1097(17)35286-5
Konstantinides S, Geibel A, Heusel G, Eibel G, Heinrich F, Kasper W, et al. Heparin plus alteplase compared with heparin alone in patients with submassive pulmonary embolism. N Engl J Med. 2002;347(15):1143-1150. https://doi.org/10.1056/NEJMoa021274. DOI: https://doi.org/10.1056/NEJMoa021274
Teleb M, Porres-Aguilar M, Anaya-Ayala JE, Rodriguez-Castro C, Porres-Muñoz M, ukherjee D. Potential role of systemic thrombolysis in acute submassive intermediate risk pulmonary embolism: Review and future perspectives. Ther Adv Cardiovasc Dis. 2016;10(2):103–110. https://doi.org/10.1177/1753944716630694. DOI: https://doi.org/10.1177/1753944716630694
Pan Q, Gao H, Wan Y, Chen Q. Comparison of Efficacy and Safety between Thrombolysis Plus Anticoagulation vs. Anticoagulation Alone for the Treatment of Acute Submassive Pulmonary Embolism: A Systematic Review and Meta-analysis. Curr Vasc Pharmacol. 2022;20(2):491-500. https://doi.org/10.2174/1570161120666220811155353. DOI: https://doi.org/10.2174/1570161120666220811155353
Bobadilla L, Scatularo CE, Antoniolli M, Lerech E, Cigalini IM, Zaidel EJ, Argentine Council of Cardiology Residents, Argentina. Impact of Reperfusion on Clinical Outcomes in Patients with Intermediate-High Risk Pulmonary Embolism. Curr Probl Cardiol. 2022;47(10):101308. https://doi.org/10.1016/j.cpcardiol.2022.101308. DOI: https://doi.org/10.1016/j.cpcardiol.2022.101308
Barnes GD, Muzikansky A, Cameron S, Giri J, Heresi GA, Jaber W, et al. Comparison of 4 Acute Pulmonary Embolism Mortality Risk Scores in Patients Evaluated by Pulmonary Embolism Response Teams. JAMA Network Open. 2020;3(8). https://doi.org/10.1001/jamanetworkopen.2020.10779 DOI: https://doi.org/10.1001/jamanetworkopen.2020.10779
Furfaro D, Stephens RS, Streiff MB, Brower R. Catheter-directed thrombolysis for intermediate-risk pulmonary embolism. Ann Am Thorac Soc. 2018;15(2):134–44. https://doi.org/10.1513/AnnalsATS.201706-467FR
Duffet L, Castellucci L, Forgie M. Pulmonary embolism: update on management and controversies. BMJ. 2020;370:m2177. https://doi.org/10.1136/bmj.m2177. DOI: https://doi.org/10.1136/bmj.m2177
Coquoz N, Weilenmann D, Stolz D, Popov V, Azzola A, Fellrath JM, et al. Multicentre observational screening survey for the detection of CTEPH following pulmonary embolism. Eur Respir J. 2018;51(4):1702505. https://doi.org/10.1183/13993003.02505-2017. DOI: https://doi.org/10.1183/13993003.02505-2017
Humbert A, Kovacs G, Hoeper M, Badagliacca R, Berger R, Brida M, et al. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Heart J. 2022;43(38):3618-3731. https://doi.org/10.1093/eurheartj/ehac237 DOI: https://doi.org/10.1093/eurheartj/ehac237
Furfaro D, Stephens R, Streiff M, Brower R. Catheter-directed Thrombolysis for Intermediate-Risk Pulmonary Embolism. Ann Am Thorac Soc. 2018;15(2):134-144. https://doi.org/10.1513/AnnalsATS.201706-467FR. DOI: https://doi.org/10.1513/AnnalsATS.201706-467FR
Xu Q, Huang K, Zhai Z, Yang Y, Wang J, Wang C. Initial thrombolysis treatment compared with anticoagulation for acute intermediate-risk pulmonary embolism: A meta-analysis. J Thorac Dis. 2015;7(5):810–821. https://doi.org/10.3978/j.issn.2072-1439.2015.04.51.
Chopard R, Behr J, Vidoni C, Ecarnot F, Meneveau N. An Update on the Management of Acute High-Risk Pulmonary Embolism. J Clin Med. 2022;11(16):4807. https://doi.org/10.3390/jcm11164807. DOI: https://doi.org/10.3390/jcm11164807
Harvey JJ, Huang S, Uberoi R. Catheter‐directed therapies for the treatment of high risk (massive) and intermediate risk (submassive) acute pulmonary embolism. Cochrane Database Syst Rev. 2022;8(8): CD013083. https://doi.org/10.1002/14651858.CD013083.pub2 DOI: https://doi.org/10.1002/14651858.CD013083.pub2
Martinez C, Chelsea M McCurdy , Maldonado S, and Lee L. Current Management of Acute Pulmonary Embolism. Ann Thorac Cardiovasc Surg 2020;26(2):65–71. https://doi.org/10.5761/atcs.ra.19-00158. DOI: https://doi.org/10.5761/atcs.ra.19-00158
Victor F. Tapson, MD, Keith Sterling, MD, Noah Jones, MD, MPH, Mahir Elder, MD. A Randomized Trial of the Optimum Duration of Acoustic Pulse Thrombolysis procedure in Acute Intermediate-Risk pulmonary Embolism. The OPTALYSE PE Trial. JACC: Cardiovascr Interv. 2018;11(14):1401-1410. https://doi.org/10.1016/j.jcin.2018.04.008. DOI: https://doi.org/10.1016/j.jcin.2018.04.008
Kahn S, de Wit K. Pulmonary embolism. N Engl J Med. 2022;387(1):45-57. https://doi.org/10.1056/NEJMcp2116489. DOI: https://doi.org/10.1056/NEJMcp2116489
Citado por
