Fibrinolytic (thrombolytic) therapy in acute pulmonary embolism and lower extremity deep vein thrombosis
- Victor F Tapson, MD
Victor F Tapson, MD
- Professor of Medicine
- Cedars-Sinai Medical Center
- Section Editor
- Jess Mandel, MD
Jess Mandel, MD
- Section Editor — Pulmonary Vascular Disease
- Professor of Medicine
- University of California, San Diego
- Deputy Editors
- Geraldine Finlay, MD
Geraldine Finlay, MD
- Deputy Editor — Pulmonary, Critical Care, and Sleep Medicine
- Associate Professor
- Tufts University School of Medicine
- Susanna I Lee, MD, PhD
Susanna I Lee, MD, PhD
- Associate Professor of Radiology
- Harvard Medical School
- Massachusetts General Hospital
Thrombolytic agents activate plasminogen to form plasmin, resulting in the accelerated lysis of thrombi. As a result, thrombolytic agents have been used in a variety of thrombotic disorders including acute myocardial infarction, stroke, acute pulmonary embolism (PE), and deep vein thrombosis (DVT).
The indications, contraindications, adverse effects, and outcomes of thrombolytic therapy in acute PE and DVT are discussed here. In addition, the types of thrombolytic agents and regimens are reviewed. Alternative treatment modalities and anticoagulation for acute PE and DVT are discussed elsewhere. (See "Treatment, prognosis, and follow-up of acute pulmonary embolism in adults" and "Overview of the treatment of lower extremity deep vein thrombosis (DVT)" and "Venous thromboembolism: Initiation of anticoagulation (first 10 days)".)
Evidence from randomized and retrospective observational studies in patients with acute pulmonary embolism (PE) indicates that thrombolytic therapy leads to early hemodynamic improvement, but at a cost of increased major bleeding. The effect of thrombolytic therapy on mortality and the frequency of recurrent thromboembolism remain questionable. (See 'Outcomes' below.)
Typically, only patients in whom the diagnosis of acute PE has been confirmed should be considered for thrombolytic therapy because the adverse effects can be devastating. For each patient, the indications and potential benefits must be carefully weighed against the risk of adverse events, taking into consideration the patient's values and preferences. (See 'Indications' below.)
Indications — Persistent hypotension or shock (ie, a systolic blood pressure <90 mmHg or a decrease in the systolic blood pressure by ≥40 mmHg from baseline) due to acute PE is the only widely accepted indication for systemic thrombolysis . In most cases, systemic thrombolytic therapy should be considered only after acute PE has been confirmed because the adverse effects of this therapy can be severe. Because a pulmonary arteriogram immediately precedes catheter-based therapy, PE can be confirmed at that time when this procedure is undertaken.
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- PULMONARY EMBOLISM
- - Hemodynamically unstable patients
- Possible indications
- - Hemodynamically stable patients
- Right ventricle dysfunction
- Cardiopulmonary resuscitation
- Extensive clot burden
- Thrombolytic agents
- - Continuous infusions
- - Bolus injections
- - Catheter-directed
- - Mortality
- - Recurrent thromboembolism
- - Bleeding
- - Hemodynamics
- - Other adverse events
- LOWER EXTREMITY DEEP VEIN THROMBOSIS
- Uncomplicated DVT
- Extensive iliofemoral DVT
- - Systemic agents
- - Catheter-directed agents
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS
- Pulmonary embolism
- Lower extremity deep vein thrombosis