P144 Case Series: Choosing Thrombolysis in Acute Pulmonary Embolism (PE) – Massiveness or Instability?
Background PE has significant mortality risk particularly in “PE with haemodynamic instability” or “massive PE” where blood pressure, attributable to PE, is sustained below 90mmHg.[1,2] Thrombolysis in this patient group is associated with reduced mortality and faster restoration of lung perfusion with approval by NICE [1,2] Another important group of patients with apparent haemodynamic stability but documented right ventricular (RV) compromise or myocardial injury (e.g. echocardiogram evidence of RV strain or raised Troponin) is recognised (“sub-massive” PE) where considerable debate remains as to reliable prognostication and appropriateness of thrombolysis.
Aims Recognising a tendency in our district general hospital to treat PE aggressively, we sought to assess our own practise with regards to thrombolytic therapy in PE to better understand our interpretation of NICE guidance and the wider literature.
Objective Assess routine quantification of haemodynamic instability of the acutely unwell patient in the clinical environment and the extent with which knowledge of right ventricular compromise and cardiac biomarkers influenced decision to thrombolyse.
Methods Retrospective review of case records. Data was extracted from the medical records by one of the authors followed by joint scrutiny by all authors.
Results From June 2010 over 24 months, 17 patients (6 males, 11 females) have been thrombolysed. Median age 62 (range 24–90). Of these one patient died 4 days later of sepsis and multi organ failure, and one developed a haematoma in her arm which resolved with conservative management.
Of these patients only two Massive i.e. haemodynamically unstable with one thrombolysed on the ITU. In the submassive PEs, supporting evidence for thrombolysis was CT in 5 cases, and echo 5, both in 2, and lab (troponin rise) in 9 cases.
Conclusion Thrombolysis in PE especially in submassive PEs remains an area of controversy and clinically a dilemma at times. Our case series shows that patient selection supported by relevant investigations, appropriate patients can benefit without any untoward events.
References NICE CG144 Venous thromboembolic diseases: full guideline.
Jaff MR et al. Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. Circulation 2011.