Farkas – Submassive PE after PEITHO long-term follow up

Long-term PEITHO Follow Up -> Thrombolytics Don’t Affect Long-Term Morbidity. Therefore, Lysis Goal is Avoiding PEA Arrest.

Original PEITHO -> Submassive PE with lysis (specifically, loaded with heparin then lysed) via tenectaplase found reduction in hemodynamic collapse, but increase in ICH. Overall, non-significant trend towards reduced all-cause mortality with lysis.

• Therefore, the point of lysing was to avoid hemodynamic collapse as well as decrease pulmonary hypertension.
• But, new work coming out showing that lysis perhaps without effect on pulmonary hypertension.

Konstantinides 2017 – Thrombolysis did not cause long-term improved functional status, nor improvements in pulmonary hypertension.

Question: If there appears to be no improvement with lysis in submassive PE from standpoint of pulmonary hypertension or functional status, why do it?

Answer: Long-term PEITHO data showing us pulmonary hypertension isn’t the issue; we lyse to avoid PEA arrest.

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Dosing Lytics -> Highly Variable Over Different Studies.

Theme remains increased dose with increased risk of bleeding. There’s indication that 100 mg alteplase is too much per Sharifi 2016.

MOPETT – 50 mg

Aykan – 25 mg over 8h in massive PE

Catheter-directed lysis studies – They’ve suggested that can do slow infusion of 25 mg alteplase at 1 mg/hr

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How to Administer Lytics

Combining lytics with heparin

• 2% ICH rates in PEITHO <- Reflects the full-dose tenectaplase and loading dose of heparin

Controlled thrombolysis

• Slow-loading -> 24 mg infused over 24 hours

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How to Risk Stratify the Individual Patient -> Chatterjee 2017

ICH risk factors in lysis for PE

• CVA or intracranial pathology
• Age
• Vascular disease (MI or peripheral vascular disease)
• Coagulopathy

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Identifying Those at Risk for “Clot-Throwing” Death <- I.e That Group That’s Not Stereotypically RV Dilatation, IVC Plethora, Syncope

Trying to find those who look fine, but are at risk of throwing clot/PEA death.

Predicated on studies saying certain factors associated with badness -> Jimenez 2014

• Proximal DVT is independent risk factor for poor outcomes
• Troponin I > 0.05 ng/ml
• BNP > 100
• Echo w/ RV dysfunction
• sPESI > 0 points
• “Immobilization” (defined as bed rest w/ bathroom privileges for preceding 1 month)