Jiang Chuan, Xie Meng
Internal Medicine, Northwell Health, Manhasset, USA.
Internal Medicine, Jamaica Hospital Medical Center, Richmond Hill, USA.
Cureus. 2021 Jun 24;13(6):e15888. doi: 10.7759/cureus.15888. eCollection 2021 Jun.
The role of thrombolytic therapy in the management of intermediate-risk pulmonary embolism is controversial. Our objective was to determine clinical outcomes for a population of patients with intermediate-risk pulmonary embolism receiving anticoagulation with and without thrombolytic therapy in a large Northeastern health system.
A retrospective cohort study.
ICU and non-ICU settings in 8 hospitals.
Hemodynamically stable patients with intermediate-risk pulmonary embolism.
Treatment arms were anticoagulation (AC) alone, AC with low dose intravenous thrombolysis, AC with full-dose intravenous thrombolysis, and AC with ultrasound-assisted, catheter-directed thrombolysis.
In 257 patients, utilizing a Bonferroni corrected P value cutoff of α = 0.003, our data shows no differences in 7 day or 30 day all-cause mortality (α = 0.37 and α = 0.04, respectively) , hospital length of stay (α = 0.31), 7 or 30 readmission rates (α = 0.97 and α = 0.84, respectively), or any major (α = 0.82) or minor bleeding events (α = 0.007) among the four treatment groups. Use of anticoagulation alone was associated with a lower duration of ICU stay (α < 0.001). There was a significant decrease in the secondary outcome of one year all-cause mortality in favor of full dose and catheter-directed thrombolytic treatment (α = 0.003). Pulmonary artery systolic pressure of > 70 mmHg was associated with increased 7-day mortality (OR 7.79, P = 0.048), and systolic blood pressure < 130 (OR 23.0; P = 0.003) and elevated N-terminal pro-B-type natriuretic peptide > 1400 pg/nl (OR 15.33; P = 0.01) were associated with increased 30- day mortality.
The use of thrombolytic therapy is not associated with a mortality benefit in the first 30 days compared to anticoagulation alone in this patient population and is associated with increased utilization of intensive care unit resources. We advocate for a conservative approach utilizing initial anticoagulation alone in a patient diagnosed with intermediate-risk pulmonary embolism.
溶栓治疗在中危肺栓塞管理中的作用存在争议。我们的目的是确定在一个大型东北医疗系统中，接受抗凝治疗且有或没有接受溶栓治疗的中危肺栓塞患者群体的临床结局。
一项回顾性队列研究。
8家医院的重症监护病房和非重症监护病房。
血流动力学稳定的中危肺栓塞患者。
治疗组分别为单纯抗凝（AC）、低剂量静脉溶栓联合AC、全剂量静脉溶栓联合AC以及超声辅助导管定向溶栓联合AC。
在257例患者中，采用Bonferroni校正后的P值临界值α = 0.003，我们的数据显示，四个治疗组在7天或30天全因死亡率（分别为α = 0.37和α = 0.04）、住院时间（α = 0.31）、7天或30天再入院率（分别为α = 0.97和α = 0.84）或任何严重（α = 0.82）或轻微出血事件（α = 0.007）方面均无差异。单纯抗凝治疗与较短的重症监护病房住院时间相关（α < 0.001）。全剂量和导管定向溶栓治疗有利于降低一年全因死亡率这一次要结局（α = 0.003）。肺动脉收缩压> 70 mmHg与7天死亡率增加相关（OR 7.79，P = 0.048），收缩压< 130（OR 23.0；P = 0.003）和N末端B型利钠肽前体升高> 1400 pg/nl（OR 15.33；P = 0.01）与30天死亡率增加相关。
在该患者群体中，与单纯抗凝相比，溶栓治疗在最初3天内未显示出死亡率获益，且与重症监护病房资源利用增加相关。我们主张对诊断为中危肺栓塞的患者采用仅初始抗凝的保守治疗方法。
