INTRODUCTION: Indications for thrombolytic therapy in massive pulmonary embolism (PE) are controversial given its short-term hemodynamic benefit without demonstrable improvement in mortality. The ACCP recommends thrombolysis in the setting of hemodynamic instability but emphasizes individualization of therapy. We present a case of massive PE successfully treated with thrombolytics for disabling hypoxemia, >2 weeks after symptom onset.
CASE PRESENTATION: A 69-year old lady, with a history of hypertension, hypothyroidism, post-hysterectomy, presented for evaluation of disabling dyspnea. She was diagnosed earlier with a saddle pulmonary embolism in an emergency room after 5 days of chest heaviness and progressive exertional dyspnea. She was discharged after IVC filter placement and anticoagulation and had been on Coumadin for 2 weeks with INR in the therapeutic range. At the time of evaluation, temperature was 97.6°F, respiratory rate 26/min, BP 130/74, with O2 saturation 94% on 6L nasal cannula. She was unable to speak in full sentences and unable to walk even a few steps. Physical examination revealed JVD of 7 cm sitting, with an accentuated P2. She had trace pitting pedal edema bilaterally. CTPA confirmed a large saddle PE with a left upper lobe pulmonary infarct, enlargement of right heart and main pulmonary artery, and moderate bilateral effusion. Echocardiogram reported normal LV function with EF 70% and RV dilatation with estimated PA pressure of >70 mmHg. We elected to proceed with thrombolytic therapy for severe hypoxemia in an attempt to improve RV afterload and lung perfusion. Once INR was <1.5 after stopping Coumadin, recombinant plasminogen activator (rTPA) was administered (100 mg IV over 2 hours). Her dyspnea and hypoxemia significantly improved within hours and she was able to ambulate 24 hours later. She was ultimately discharged on Coumadin without the need for supplemental oxygen. At 6 months follow-up, she has resumed her full time job as a school teacher and CTPA documented complete resolution of the saddle embolus and effusion with significant shrinkage in the size of the infarct.
DISCUSSION: The mortality in patients with complications of PE, such as high ventricular pressures and high pulmonary artery pressures is higher than mortality in patients with uncomplicated PE. Studies have shown that thrombolytics do promote rapid embolic resolution, even though there is no long-term mortality benefit to more rapid clot resolution. The ongoing debate on the indication for thrombolysis for PE defines benefit in terms of mortality. Our case highlights TWO additional points: 1) Quality of life is an important consideration in the balance of benefit vs. risk; and 2) Even 2 weeks after onset (the recommended time limit for effective thrombolysis), thrombolysis can still resolve emboli in some patients. Thus, in patients with a large clot burden and disabling symptoms in spite of standard therapy for PE, thrombolysis should be considered even after 2 weeks, as long as the risk of bleeding is tolerable.
CONCLUSIONS: In patients with high clot burden and disabling symptoms in spite of standard therapy for PE, consideration should be given to use of thrombolytics, even in the absence of hemodynamic instability.
Reference #1 Jack Hirsh, Gordon Guyatt,Gregory W. Albers,and Holger J. Schünemann. The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy: Evidence-Based Guidelines:Chest September 2004 ;126:172S-173S.
Reference #2 Jamie L. Todd, MD and Victor F. Tapson, MD Thrombolytic Therapy for Acute Pulmonary Embolism A Critical Appraisal. CHEST May 2009 vol.135 no.5 1321-1329
DISCLOSURE: The following authors have nothing to disclose: Ngozika Orjioke, Renli Qiao
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