Transforming and simplifying the treatment of pulmonary embolism: "safe dose" thrombolysis plus new oral anticoagulants.
BACKGROUND
Administration of systemic thrombolysis in pulmonary embolism (PE) has been limited to severe forms due to the risk of intracerebral hemorrhage (ICH). There is growing evidence from small studies that low-dose systemic thrombolysis has equal efficacy to standard dose, while eliminating the risk of ICH. Little data exists on the combined use of low-dose systemic thrombolysis and new oral anticoagulants (NOAC). We evaluated the clinical and echocardiographic outcome of patients treated with low or "safe dose" thrombolysis (SDT) and NOAC at intermediate term.


METHODS
We retrospectively identified 159 patients with massive and submassive PE who were treated with SDT and NOAC over a 2-year period by our group. They were followed prospectively for PE-related mortality, recurrent PE, bleeding, change in right/left ventricle (RV/LV) size, pulmonary artery systolic pressure (PASP), and clinical improvement at a mean follow-up of 18 ± 3 months.


RESULTS
At 6 months, the RV/LV size was reduced from 1.29 ± 0.28 to 0.89 ± 0.03 (p < 0.001). The PASP dropped from 53.12 ± 3.85 mmHg to 30.39 ± 3.93 mmHg (p < 0.001). There was no ICH or in-hospital major or minor bleeding. At 18 months, three patients died of cancer. Recurrent PE developed in one patient who had been later switched to warfarin. The duration of hospitalization was 1.8 ± 0.3 days.


CONCLUSIONS
With combination of SDT and NOAC, treatment of massive and submassive PE becomes identical and is transformed from an "anticoagulation first" to a "thrombolysis first" approach, thereby making treatment streamlined, simple, safe and effective, accessible and inexpensive.
Arizona Cardiovascular Consultants & Vein Clinic, 3850 E. Baseline Road, Building 1, Suite 102, Mesa, AZ, 85206, USA, seyedmohsensharifi@yahoo.com.
Mohsen
M
Sharifi
Zoltan
Z
Vajo
Wilbur
W
Freeman
Curt
C
Bay
Mirali
M
Sharifi
Frederic
F
Schwartz
D000284:Administration, Oral; D000368:Aged; D000925:Anticoagulants / Q000008:administration & dosage* / Q000009:adverse effects; D004359:Drug Therapy, Combination; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage* / Q000009:adverse effects; D006470:Hemorrhage / Q000139:chemically induced; D006760:Hospitalization; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D011655:Pulmonary Embolism / Q000097:blood / Q000150:complications / Q000175:diagnosis / Q000188:drug therapy* / Q000503:physiopathology; D012008:Recurrence; D012189:Retrospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D015912:Thrombolytic Therapy / Q000009:adverse effects; D013997:Time Factors; D016896:Treatment Outcome
D000925:Anticoagulants; D005343:Fibrinolytic Agents