Intermediate Risk PE's Need Thrombolysis, but this Is Dangerous: Will This Trial Open the Door for 'Safe Dose Thrombolysis'
On the 21st of February this year we mentioned a paper by Sharifi et al. who introduced a new concept of 'Safe Dose Thrombolysis'. Background is the fact that for most patients, e.g. intermediate risk pulmonary embolism (PE), thrombolysis is not recommended due to the risk of bleeding. The question though remained wether intermediate risk patients actually also would benefit of thrombolysis in terms of outcome.
In the recent NEJM now a trial is presented where the investigators focused on exactly this so called 'intermediate risk' group of patients. They randomized 1005 patients with PE who had right ventricular dysfunction on echocardiography or computed tomography, as well as myocardial injury as indicated by a positive test for cardiac troponin I or troponin T. The one group received tenecteplase and heparin, the other only heparin.
Result: Thrombolysis prevented hemodynamic decompensation and death... but at the same time increased the risk for major hemorrhage and stroke. What a dilemma!
That's where I feel 'Safe Dose Thrombolysis' might be interesting to look at. Now there's a good topic for your next publication in the NEJM, go for it!
(and please don't forget to mention us for the great idea ; )
Meyer G et al. N Engl J Med 2014; 370:1402-1411
Sharifi M et al. Clin Cardiol. 2014 Feb;37(2):78-82