Thrombolysis in Massive Pulmonary Embolism

Aka: Thrombolysis in Massive Pulmonary Embolism, Pulmonary Embolism Thrombolysis, PE Thrombolysis

1. See Also
   1. Pulmonary Embolism
   2. Pulmonary Embolism Management
   3. Thrombolytic
   4. Thrombolysis in Cerebrovascular Accident
   5. Thrombolysis in ST Elevation Myocardial Infarction
   6. t-PA (Alteplase)
2. Indications
   1. Massive Pulmonary Embolism (absolute indications)
      1. Hypotension
         1. Systolic Blood Pressure <90 mmHg or
         2. Systolic Blood Pressure drops >40 mmHg from baseline for at least 15 minutes
      2. Systemic hypoperfusion
   2. Submassive Pulmonary Embolism with significant cardiopulmonary findings (relative indications, treatment is controversial)
      1. Right ventricular dysfunction (RV Strain)
         1. Serum Troponin elevation or
         2. ntBNP >900 pg/ml or (BNP >90 pg/ml) or
         3. Echocardiogram with right ventricular dilation or hypokinesis
      2. Pulmonary Hypertension
      3. Extensive Deep Vein Thrombosis
      4. Prevent recurrent Pulmonary Embolism
3. Contraindications
   1. See Thrombolytic Contraindication
4. Efficacy
   1. Only benefit may be in massive Pulmonary Embolism
      1. Thrombolysis offers faster clot lysis than Heparin
      2. Short-term better pulmonary artery perfusion
      3. Benefit is in first 24-48 hours
   2. Thrombolysis longterm outcomes are similar to Heparin
      1. No difference in mortality
      2. No difference in Pulmonary Embolism resolution
      3. No difference in recurrent PE
   3. Local or directed Thrombolysis offers no benefit
   4. References
      1. (1974) JAMA 229:1606-13
      2. Levine (1990) Chest 98:1473-9
      3. Dalla-Volta (1992) J Am Coll Cardiol 20:520-6
5. Protocol
   1. General
      1. Administered with Heparin
      2. Indicated within 14 days of severe PE onset
      3. Outcomes between agents are similar at 24 hours (however tPA is typically used)
      4. Meyer (1992) J Am Coll Cardiol 19:239-45
   2. Agents
      1. T-PA (Alteplase) - preferred agent
         1. T-PA 100 mg IV peripheral infusion over 2 hours
         2. Restart Heparin when PTT less than twice normal
      2. Streptokinase
         1. Load: 250,000 units over 30 minutes
         2. Maintenance: 100,000 units per hour for 24 hours
      3. Urokinase
         1. Load: 4400 units/kg over 10 minutes
         2. Maintenance: 4400 units/kg per hour for 12-24 hours
   3. Monitoring
      1. Obtain PTT after Thrombolytic infusion and q4 hours
      2. Start Heparin if PTT falls below 2.5x normal control
      3. Maintain PTT 1.5 to 2.5 times normal
6. Complications
   1. See Complications in Thrombolysis
7. References
   1. (2000) Eur Heart J 21(16): 1301-36
   2. Almoosa (2002) Am Fam Physician 65(6):1097-1102
   3. Jaff (2011) Circulation 123: 1788-830