title: Risks for major bleeding from thrombolytic therapy in patients with acute pulmonary embolism. Consideration of noninvasive management.
abstract: OBJECTIVE
  To assess the relative risks for bleeding with thrombolytic therapy in patients who are managed using pulmonary angiograms compared with those managed using noninvasive tests, primarily the ventilation-perfusion lung scan.
  
  
  METHODS
  A decision analysis based on data from other studies.
  
  
  METHODS
  The risk for major bleeding in patients with pulmonary embolism who receive thrombolytic therapy after a noninvasive diagnosis was assessed from complications of thrombolytic therapy in patients with myocardial infarction, assuming that the same risk ratio for major bleeding when comparing an invasive with a noninvasive approach applied to patients with pulmonary embolism. The risk ratio was 3.3 (95% CI, 1.5 to 9.8) for major bleeding in patients with myocardial infarction. One or more major complications of pulmonary angiography occurred in 1.3% of patients (CI, 0.6% to 1.9%).
  
  
  RESULTS
  The average reported risk was 14% (18 of 129 patients) (CI, 7.9% to 20.1%) for major bleeding in patients who had pulmonary angiography before receiving tissue plasminogen activator (tPA). The estimated risk was 4.2% (estimated CI, 1.4% to 9.3%) for major bleeding with tPA after a noninvasive diagnosis of pulmonary embolism. Assuming a risk of 1.3% for major complications from pulmonary angiography, a risk for major hemorrhage of 14.0% for an invasive diagnosis, and a risk of 4.2% for a noninvasive diagnosis, fewer complications would occur with noninvasive management if the prevalence of pulmonary embolism exceeded 21%.
  
  
  CONCLUSIONS
  Among patients with suspected pulmonary embolism who are candidates for thrombolytic therapy, it is safer to use noninvasive diagnostic tests in many patients.
authors.affiliation: Henry Ford Heart and Vascular Institute, Detroit, Michigan.
authors.forename: P D
authors.initials: PD
authors.lastname: Stein
authors.forename: R D
authors.initials: RD
authors.lastname: Hull
authors.forename: G
authors.initials: G
authors.lastname: Raskob
mesh_terms: D000208:Acute Disease; D000792:Angiography / Q000009:adverse effects; D003661:Decision Support Techniques; D006470:Hemorrhage / Q000139:chemically induced*; D006801:Humans; D011655:Pulmonary Embolism / Q000000981:diagnostic imaging / Q000188:drug therapy*; D012307:Risk Factors; D015912:Thrombolytic Therapy / Q000009:adverse effects*; D010959:Tissue Plasminogen Activator / Q000009:adverse effects*; D014692:Ventilation-Perfusion Ratio
chemical_list: D010959:Tissue Plasminogen Activator