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.
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
How to Administer Lytics
Combining lytics with heparin
- 2% ICH rates in PEITHO <- Reflects the full-dose tenectaplase and loading dose of heparin
- Slow-loading -> 24 mg infused over 24 hours
How to Risk Stratify the Individual Patient -> Chatterjee 2017
ICH risk factors in lysis for PE
- CVA or intracranial pathology
- Vascular disease (MI or peripheral vascular disease)
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)