High dose and short-term streptokinase infusion in patients with pulmonary embolism: prospective with seven-year follow-up trial.
BACKGROUND
High dose and short-term streptokinase infusion has proved to improve survival among few patients with pulmonary embolism and cardiogenic shock, without increasing hemorrhagic complications. However its efficacy and safety in terms of long follow-up and in major number of patients requires to be established.


METHODS
Patients with pulmonary embolism proved through high probability V/Q lung scan, suggestive echocardiogram, or deep venous thrombosis were enrolled. All were assigned to receive 1,500,000 IU in one-hour streptokinase infusion. The primary end point was efficacy and safety of streptokinase regimen in terms of pulmonary arterial hypertension, right ventricular dysfunction, perfusion abnormalities, recurrence, mortality and hemorrhagic complications. In long-term follow-up, we assessed functional class, recurrence, chronic pulmonary arterial hypertension, postthrombotic-syndrome and mortality.


RESULTS
A total of 40 consecutive patients (47.3+/-15.3 years of age) with large or massive pulmonary embolism were enrolled. In 35 patients high dose and short-term streptokinase regimen reversed acute pulmonary arterial hypertension, clinical and echocardiographic evidence of right ventricular dysfunction and improved pulmonary perfusion without increasing hemorrhagic complications. In acute phase 5 patients died, necropsy study performed in 4 patients showed massive pulmonary embolism and right ventricular myocardial infarction, without significant coronary arterial obstruction. Risk factors for mortality and recurrence were: right ventricular global hypokinesis (p<0.0001), 6 hours or over between onset symptoms and streptokinase regimen (p=0.02), severe systolic pulmonary arterial hypertension (p=0.001) right ventricular hypokinesis (p=0.001), hypoxemia (p=0.02) and right ventricular acute myocardial infarction (p<0.0001). Right ventricular hypokinesis (p=0.02) was the only independent risk factor for recurrence. In a seven-year follow-up of the original 35 patients who survived in acute phase, 2 patients were lost and 33 are alive, in functional class I, without recurrence or chronic pulmonary arterial hypertension.


CONCLUSIONS
Our report indicates that among properly selected high-risk PE patients, short-term streptokinase infusion is effective and safe.
Jerjes-Sanchez
C
C
Emergency Care Department, Hospital de Cardiologia, Centro Médico Nacional, IMSS, Mexico City. jerjes@infosel.net.mx
Ramirez-Rivera
A
A
Arriaga-Nava
R
R
Iglesias-Gonzalez
S
S
Gutierrez
P
P
Ibarra-Perez
C
C
Martinez
A
A
Valencia
S
S
Rosado-Buzzo
A
A
Pierzo
J A
JA
Rosas
E
E
D000328:Adult; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage* / Q000633:toxicity; D005500:Follow-Up Studies; D006470:Hemorrhage / Q000139:chemically induced; D006801:Humans; D006976:Hypertension, Pulmonary / Q000188:drug therapy / Q000209:etiology; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D011655:Pulmonary Embolism / Q000150:complications / Q000188:drug therapy* / Q000401:mortality; D012039:Regional Blood Flow; D012307:Risk Factors; D055502:Secondary Prevention; D013300:Streptokinase / Q000008:administration & dosage* / Q000633:toxicity; D016019:Survival Analysis; D013810:Therapeutic Equivalency; D018497:Ventricular Dysfunction, Right / Q000188:drug therapy / Q000209:etiology
D005343:Fibrinolytic Agents; D013300:Streptokinase