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Comment & Response
October 15, 2014

Benefits and Risks Associated With Thrombolysis for Pulmonary Embolism

Author Affiliations
  • 1Section of Pulmonary and Critical Care Medicine, Boston University School of Medicine, Boston, Massachusetts
  • 2Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
  • 3Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada

Copyright 2014 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.

JAMA. 2014;312(15):1588-1589. doi:10.1001/jama.2014.10780

To the Editor Dr Chatterjee and colleagues1 performed a meta-analysis comparing thrombolysis with anticoagulation for pulmonary embolism using the Peto method to determine pooled odds ratios (ORs) because of low expected event rates among included trials. We suggest that this method is flawed for several reasons.

First, although simulation suggests that the Peto method may outperform standard Mantel-Haenszel OR estimates when event rates are less than 1%,2 the overall risk of mortality after pulmonary embolism is higher (approximately 3%). The Peto method may produce biased estimates with higher events rates.2 Second, the Peto and other methods ignore trials with zero events, creating another source of bias away from no effect.3 Third, the Peto fixed-effects model assumes that included studies measured a single underlying effect. It seems unlikely that thrombolytic trials spanning more than 30 years and using different selection criteria and outcome measures would generate 1 treatment effect.

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