POTD: TPA in PE
Massive PE can lead to hemodynamic instability and death
Smaller but clinically significant PEs can lead to pulmonary hypertension, RV dysfunction and subsequently poor quality of life (decreased exercise tolerance and even dyspnea at rest)
TPA in PE is surrounded by controversy with various opinions on the matter
AHA:
Massive: hemodynamic instability defined as SBP<90 (or 40 point drop from baseline) for >15 minutes=
Thrombolysis indicated unless there are contraindications
Sub-massive: hemodynamically stable but with signs of RV strain (elevated troponin/BNP, echo findings of RV dysfunction) = Thrombolysis may be considered (level IIb/C)
ACEP:
Hemodynamically unstable patients: Thrombolysis indicated if benefits outweigh risks of bleeding
Level B recommendation
Hemodynamically stable patients: insufficient evidence to do thrombolysis
MOPETT (Moderate Pulmonary Embolism Treated with Thrombolysis):
If
Symptomatic moderate defined as ≥2 signs/symptoms (7 total in inclusion criteria) in addition to CTPA involvement of >70% involvement of thrombus in ≥2 lobar, or left or right main pulmonary arteries
Ventilation/perfusion scan showing mismatch in ≥2 lobes
SBP<95 excluded
Then
enoxaparin/heparin only vs enoxaparin/heparin + half dose tPA (10mg bolus then 40mg over 2 hours)
primary end point: pulmonary HTN at 28 months
rates in treatment group=16%, control group=57%
combined end point: pulmonary HTN at 28 months + recurrent PE
treatment group=16%, control group=63%
no patients in either group bled
Conclusion:
Studies suggest that half-dose thrombolysis is safe/effective in the treatment of moderate PE, with a significant immediate reduction in pulmonary artery pressure that was maintained at 28 months
”Thrombolytics have demonstrated faster improvements in RV function and pulmonary perfusion, but these benefits have not translated to improvements in mortality.”
So the measured outcome is of questionable significance as opposed to actual measurements of quality-of-life
Perhaps consider in your young patient in whom potential improvement in exercise tolerance in remaining lifetime may be more relevant than in older, immobile patients
Stay well,
TR Adam