Pulmonary Embolism: Thrombolytic Therapy Benefits Must Be Balanced With Risk of Cerebral Bleed

Jay Giri, MD MPH Assistant Professor, Perelman School of Medicine Director, Peripheral Intervention Interventional Cardiology & Vascular Medicine Cardiovascular Division University of PennsylvaniaMedicalResearch Interview with:
Jay Giri, MD MPH
Assistant Professor, Perelman School of Medicine
Director, Peripheral Intervention
Interventional Cardiology & Vascular Medicine
Cardiovascular Division
University of Pennsylvania

MedicalResearch: What are the main findings of the study?

Dr. Giri: Use of thrombolytics was associated with lower all-cause mortality and increased rates of intracranial hemorrhage.  These results were also seen in intermediate-risk pulmonary embolism.  Finally, it appeared that patients under age 65 might be at less bleeding risk from thrombolytics.

MedicalResearch: Were any of the findings unexpected?

Dr. Giri: Most importantly, we discovered that thrombolytic therapy was associated with mortality benefit in intermediate-risk pulmonary embolism.  This is a hotly debated topic and no prior study has had the statistical power to demonstrate this finding.  Of course, this potential benefit must be balanced against potential bleeding risks in the individual patient which we also attempted to clarify.

MedicalResearch: What should clinicians and patients take away from your report?

Dr. Giri: For intermediate risk pulmonary embolism, clinicians should consider a tailored approach to therapy for an individual patient, taking into account potential bleeding risks as well as potential benefits in symptom resolution and mortality.

MedicalResearch: What recommendations do you have for future research as a result of this study?

Dr. Giri: Future research should be dedicated to development of risk stratification models for bleeding and intracranial hemorrhage in all patients, but especially the elderly, with thrombolytic therapy.  Additionally, research should focus on standardization of dosages of thrombolytics and method of administration (peripheral intravenous versus catheter-directed therapy into the pulmonary arteries) to accrue maximal clinical benefits with minimization of bleeding risk.

There is a current effort to expand the use catheter-directed thrombolytic therapy into intermediate-risk pulmonary embolism.  While intuitively appealing, we must hold this therapy to the same threshold of evidence that peripheral IV-based thrombolysis has been measured by, especially given dramatically increased costs with modern systems.   Thus far, significant evidence from randomized trials has not been accumulated for this approach.

Finally, future trials should mandate longer-term follow-up of pulmonary embolism patients treated with thrombolytics to determine whether late benefits/harms emerge from their use.

Citation:

Thrombolysis for Pulmonary Embolism and Risk of All-Cause Mortality, Major Bleeding, and Intracranial Hemorrhage: A Meta-analysis
Saurav Chatterjee MD, Anasua Chakraborty MD, Ido Weinberg MD, Mitul Kadakia MD, Robert L. Wilensky MD, Partha Sardar MD, Dharam J. Kumbhani MD, SM, MRCP, Debabrata Mukherjee MD, MS, Michael R. Jaff DO, Jay Giri MD, MPH
JAMA. 2014;311(23):2414-2421. doi:10.1001/jama.2014.5990

 

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