ANN B.NATTINGERMD, MPH
Although the mortality rate for those with acute PE is low, certain patients are at high risk.1 Therefore, optimal management strategies should rely on risk stratification rather than “one-size-fits-all” treatment.2 In high-risk patients, the use of aggressive treatment could be justified. Despite the lack of definitive evidence,3 massive PE associated with cardiogenic shock, given the high mortality rate, is a widely accepted indication for thrombolysis.4,5 At the other extreme, the risks of thrombolysis are not justified in patients with an anatomically small PE that causes no elevation in RV afterload. The mortality rate for these patients is low, with most patients dying from underlying conditions rather than from PE.6 In a meta-analysis of 5 studies involving 1302 patients with PE treated by heparin followed by warfarin, the rate of death due to PE was only 1.5%.7 In such patients, the expected improvement in survival would be offset by the risk of life-threatening or disabling hemorrhage with thrombolytic treatment.8
Thabut G, Logeart D. Thrombolysis for Pulmonary Embolism in Patients With Right Ventricular Dysfunction: Con. Arch Intern Med. 2005;165(19):2200–2203. doi:10.1001/archinte.165.19.2200
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