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Thrombolytic Treatment and Outcomes of Acute Pulmonary Embolism
Study Questions:
What is the trend in use of systemic thrombolysis and associated outcomes for patients with acute pulmonary embolism (PE)?
Methods:
The authors explored treatment approaches and in-hospital outcomes for 885,806 patients with acute PE in Germany between 2005 and 2015. They performed a claims-based analysis to identify acute PE, shock, use of cardiopulmonary resuscitation (CPR) and mechanical ventilation, and intracerebral bleeding. The primary outcome was in-hospital death and intracerebral bleeding.
Results:
The incidence of acute PE was 99/100,000 population/year, increasing from 85/100,000 in 2005 to 109/100,000 in 2015 (p < 0.001). During the same time, the in-hospital case fatality rate decreased from 20.4% to 13.9% (p < 0.001). Systemic thrombolysis use increased slightly from 3.1% of patients in 2005 to 4.4% of patients in 2015 (p < 0.001). Use of thrombolysis was associated with a lower in-hospital rate among patients with shock not requiring CPR or mechanical ventilation (odds ratio [OR], 0.42; 95% confidence interval [CI], 0.37-0.48) as well as patients who underwent CPR (OR, 0.92; 95% CI, 0.87-0.97). However, systemic thrombolysis was only administered to 23.1% of patients with hemodynamic instability. Intracerebral hemorrhage occurred in 0.6% of all patients with acute PE, more commonly in those who received systemic thrombolysis than those who did not (1.7% vs. 0.5%, p < 0.001).
Conclusions:
The authors concluded that the proportion of PE patients treated with systemic thrombolysis increased slightly between 2005 and 2015, but only a minority of patients with hemodynamic instability receive this therapy. They also noted that use of systemic thrombolysis was associated with reduced in-hospital mortality among patients with shock and those who underwent CPR.
Perspective:
This nationwide study of acute PE demonstrates a few important findings. First, the diagnosis (and associated hospital admission) of acute PE increased between 2005 and 2015, but overall mortality risk declined markedly (6.5% absolute reduction). This is unlikely to be related to the small increase in use of systemic thrombolysis (1.3% absolute increase). However, among the highest risk patients who did receive systemic thrombolysis, they were less likely to experience in-hospital mortality, especially for those patients who did not require CPR or mechanical ventilation. And the overall rate of intracranial hemorrhage was quite low. However, no details about the dose of systemic thrombolysis were available. And these data may not be generalizable to the use of catheter-based thrombolysis, which is more common in many US-based health systems. Further data exploring the clinical outcomes of catheter-based thrombolysis versus anticoagulation alone, especially among higher-risk patients with acute PE, are needed.
Clinical Topics: Arrhythmias and Clinical EP, Prevention, Vascular Medicine, SCD/Ventricular Arrhythmias
Keywords: Cardiopulmonary Resuscitation, Cerebral Hemorrhage, Fibrinolytic Agents, Hemodynamics, Hospital Mortality, Intracranial Hemorrhages, Pulmonary Embolism, Respiration, Artificial, Secondary Prevention, Shock, Thrombolytic Therapy, Treatment Outcome, Vascular Diseases
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