Clinical study: pulmonary embolism
Thrombolytic therapy of pulmonary embolism: A meta-analysis

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Abstract

Objectives

We sought to assess the efficacy and safety of thrombolytic therapy in patients with an acute pulmonary embolism (PE).

Background

Thrombolytic therapy is approved for the treatment of acute PE; however, the safety and efficacy of this therapy remain debated.

Methods

A meta-analysis of randomized, controlled trials comparing thrombolytic agents with intravenous heparin in patients with acute PE was performed. Trials were identified through a combined search of the MEDLINE, EMBASE, and Current Contents databases. Three outcome measures were assessed: 1) mortality, 2) recurrence of PE, and 3) major hemorrhage.

Results

Nine trials including 461 patients were identified. Compared with intravenous heparin, thrombolytic therapy had no significant effect on mortality (relative risk [RR] 0.63, 95% confidence interval [CI] 0.32 to 1.23) or the recurrence of PE (RR 0.59, 95% CI 0.30 to 1.18), but was associated with an increased risk of major hemorrhage (RR 1.76, 95% CI 1.04 to 2.98). These results were homogeneous and largely unaffected by the formulation of thrombolytic agent, the clinical severity of PE, the extent of vascular obstruction determined radiologically, or the methodologic quality of the included trials.

Conclusions

Compared with intravenous heparin, thrombolytic therapy does not appear to have therapeutic benefit in unselected patients with acute PE, but it is associated with an increased risk of major hemorrhage. Given the small number of patients included in the randomized trials thus far, the negative results in terms of the efficacy outcomes should be interpreted with caution. Definitive evidence of the utility of thrombolytic therapy in this setting requires a large, randomized, controlled trial.

Abbreviations

CI
confidence interval
PE
pulmonary embolism
RR
relative risk
RV
right ventricular
rt-PA
recombinant tissue-type plasminogen activator

Cited by (0)

Dr. Myers is supported by the Dr. V. Feinman Hepatology Fellowship from the Canadian Association for the Study of the Liver and Schering Canada, as well as by the Detweiler Traveling Fellowship from the Royal College of Physicians and Surgeons of Canada.