title: Life-saving systemic thrombolysis in a patient with massive pulmonary embolism and a recent hemorrhagic cerebrovascular accident.
abstract: Massive pulmonary embolism is associated with mortality rates exceeding 50%. Current practice guidelines include the immediate administration of thrombolytic therapy in the absence of contraindications. However, thrombolysis for pulmonary embolism is said to be absolutely contraindicated in the presence of recent hemorrhagic stroke and other conditions. The current contraindications to thrombolytic therapy have been extrapolated from data on acute coronary syndrome and are not specific for venous thromboembolic disease. Some investigators have proposed that the current contraindications be viewed as relative, rather than absolute, in cases of high-risk pulmonary embolism. We present the case of a 60-year-old woman in whom massive pulmonary embolism led to cardiac arrest with pulseless electrical activity. Eight weeks earlier, she had sustained a hemorrhagic cerebrovascular accident-a classic absolute contraindication to thrombolytic therapy. Despite this practice guideline, we administered tissue plasminogen activator systemically in order to save the patient's life. This therapy did not evoke intracranial bleeding, and the patient was eventually discharged from the hospital. Until guidelines specific to venous thromboembolic disease are developed, we think that the current contraindications to thrombolysis should be considered on an individual basis in patients who are at high risk of death from massive pulmonary embolism.
authors.affiliation: Department of Internal Medicine (Drs. Bottinor and Turlington) and Department of Internal Medicine, Division of Pulmonary/Critical Care Medicine (Dr. Malhotra), Virginia Commonwealth University Health System; Pauley Heart Center Division of Cardiology (Drs. Abbate, Jovin, and Raza, and Ms Roberts); Richmond, Virginia 23298; and Division of Cardiology (Dr. Jovin), Hunter Holmes McGuire VA Medical Center, Richmond, Virginia 23249.
authors.forename: Wendy
authors.initials: W
authors.lastname: Bottinor
authors.affiliation: Department of Internal Medicine (Drs. Bottinor and Turlington) and Department of Internal Medicine, Division of Pulmonary/Critical Care Medicine (Dr. Malhotra), Virginia Commonwealth University Health System; Pauley Heart Center Division of Cardiology (Drs. Abbate, Jovin, and Raza, and Ms Roberts); Richmond, Virginia 23298; and Division of Cardiology (Dr. Jovin), Hunter Holmes McGuire VA Medical Center, Richmond, Virginia 23249.
authors.forename: Jeremy
authors.initials: J
authors.lastname: Turlington
authors.affiliation: Department of Internal Medicine (Drs. Bottinor and Turlington) and Department of Internal Medicine, Division of Pulmonary/Critical Care Medicine (Dr. Malhotra), Virginia Commonwealth University Health System; Pauley Heart Center Division of Cardiology (Drs. Abbate, Jovin, and Raza, and Ms Roberts); Richmond, Virginia 23298; and Division of Cardiology (Dr. Jovin), Hunter Holmes McGuire VA Medical Center, Richmond, Virginia 23249.
authors.forename: Syed
authors.initials: S
authors.lastname: Raza
authors.affiliation: Department of Internal Medicine (Drs. Bottinor and Turlington) and Department of Internal Medicine, Division of Pulmonary/Critical Care Medicine (Dr. Malhotra), Virginia Commonwealth University Health System; Pauley Heart Center Division of Cardiology (Drs. Abbate, Jovin, and Raza, and Ms Roberts); Richmond, Virginia 23298; and Division of Cardiology (Dr. Jovin), Hunter Holmes McGuire VA Medical Center, Richmond, Virginia 23249.
authors.forename: Charlotte S
authors.initials: CS
authors.lastname: Roberts
authors.affiliation: Department of Internal Medicine (Drs. Bottinor and Turlington) and Department of Internal Medicine, Division of Pulmonary/Critical Care Medicine (Dr. Malhotra), Virginia Commonwealth University Health System; Pauley Heart Center Division of Cardiology (Drs. Abbate, Jovin, and Raza, and Ms Roberts); Richmond, Virginia 23298; and Division of Cardiology (Dr. Jovin), Hunter Holmes McGuire VA Medical Center, Richmond, Virginia 23249.
authors.forename: Rajiv
authors.initials: R
authors.lastname: Malhotra
authors.affiliation: Department of Internal Medicine (Drs. Bottinor and Turlington) and Department of Internal Medicine, Division of Pulmonary/Critical Care Medicine (Dr. Malhotra), Virginia Commonwealth University Health System; Pauley Heart Center Division of Cardiology (Drs. Abbate, Jovin, and Raza, and Ms Roberts); Richmond, Virginia 23298; and Division of Cardiology (Dr. Jovin), Hunter Holmes McGuire VA Medical Center, Richmond, Virginia 23249.
authors.forename: Ion S
authors.initials: IS
authors.lastname: Jovin
authors.affiliation: Department of Internal Medicine (Drs. Bottinor and Turlington) and Department of Internal Medicine, Division of Pulmonary/Critical Care Medicine (Dr. Malhotra), Virginia Commonwealth University Health System; Pauley Heart Center Division of Cardiology (Drs. Abbate, Jovin, and Raza, and Ms Roberts); Richmond, Virginia 23298; and Division of Cardiology (Dr. Jovin), Hunter Holmes McGuire VA Medical Center, Richmond, Virginia 23249.
authors.forename: Antonio
authors.initials: A
authors.lastname: Abbate
mesh_terms: D002543:Cerebral Hemorrhage / Q000150:complications*; D000075202:Contraindications; D004452:Echocardiography; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage; D006323:Heart Arrest / Q000209:etiology; D006801:Humans; D008875:Middle Aged; D017410:Practice Guidelines as Topic; D011655:Pulmonary Embolism / Q000175:diagnosis / Q000209:etiology / Q000503:physiopathology / Q000628:therapy; D018570:Risk Assessment; D020521:Stroke / Q000150:complications*; D015912:Thrombolytic Therapy / Q000379:methods; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage*; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator
keywords: Evidence-based medicine; heart arrest/therapy; practice guidelines as topic; pulmonary embolism/complications/drug therapy; risk assessment; thrombolytic therapy/methods; tissue plasminogen activator/con-traindications/therapeutic use; treatment outcome