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Int J Angiol 2023; 32(02): 131-135
DOI: 10.1055/s-0042-1758386
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Low-Dose Alteplase versus Conventional Anticoagulation to treat Submassive Pulmonary Embolism in Hispanic Patients

Emily Zientek
1   Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, Texas
,
Kelsey Talkington
1   Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, Texas
,
Joshua Gardner
1   Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, Texas
,
Yi Guo
2   Department of Pharmacy, Clinical Pharmacy Services, University Medical Center of El Paso, El Paso, Texas
,
Debabrata Mukherjee 
1   Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, Texas
3   Department of Internal Medicine, Division of Cardiovascular Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, Texas
,
Manu Rajachandran
1   Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, Texas
3   Department of Internal Medicine, Division of Cardiovascular Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, Texas
,
Tariq S. Siddiqui
1   Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, Texas
3   Department of Internal Medicine, Division of Cardiovascular Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, Texas
,
Nils P. Nickel
1   Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, Texas
4   Department of Internal Medicine, Division of Pulmonary and Critical Care, Texas Tech University Health Sciences Center El Paso, El Paso, Texas
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Abstract

The use of low-dose tissue plasminogen activator (tPA) in Hispanic patients with submassive pulmonary embolism (PE) is understudied.

The purpose of this study is to explore the use of low-dose tPA in Hispanic patients with submissive PE compared with counterparts that received heparin alone.

We retrospectively analyzed a single-center registry of patients with acute PE between 2016 and 2022. Out of 72 patients admitted for acute PE and cor pulmonale, we identified six patients that were treated with conventional anticoagulation (heparin alone) and six patients who received low-dose tPA (and heparin afterward). We analyzed if low-dose tPA was associated with differences in length of stay (LOS) and bleeding complications.

Both groups were similar in regard to age, gender, and PE severity (based on Pulmonary Embolism Severity Index scores). Mean total LOS for the low-dose tPA group was 5.3 days, compared with 7.3 days in the heparin group (p = 0.29). Mean intensive care unit (ICU) LOS for the low-dose tPA group was 1.3 days compared with 3 days in the heparin group (p = 0.035). There were no clinically relevant bleeding complications documented in either the heparin or the low-dose tPA group.

Low-dose tPA for submassive PE in Hispanic patients was associated with a shorter ICU LOS without a significant increase in bleeding risk. Low-dose tPA appears to be a reasonable treatment option in Hispanic patients with submassive PE who are not at high bleeding risk (<5%).

Keywords

pulmonary embolism - length of stay - Hispanic - hemodynamics - low-dose alteplase - tissue plasminogen activator - anticoagulation


Publication History

Article published online:
03 December 2022

© 2022. International College of Angiology. This article is published by Thieme.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Wan S, Quinlan DJ, Agnelli G, Eikelboom JW. Thrombolysis compared with heparin for the initial treatment of pulmonary embolism: a meta-analysis of the randomized controlled trials. Circulation 2004; 110 (06) 744-749
    CrossrefPubMedGoogle Scholar
  • 2 Stein PD, Matta F. Thrombolytic therapy in unstable patients with acute pulmonary embolism: saves lives but underused. Am J Med 2012; 125 (05) 465-470
    CrossrefPubMedGoogle Scholar
  • 3 Meyer G, Vicaut E, Danays T. et al; PEITHO Investigators. Fibrinolysis for patients with intermediate-risk pulmonary embolism. N Engl J Med 2014; 370 (15) 1402-1411
    CrossrefPubMedGoogle Scholar
  • 4 Kline JA, Nordenholz KE, Courtney DM. et al. Treatment of submassive pulmonary embolism with tenecteplase or placebo: cardiopulmonary outcomes at 3 months: multicenter double-blind, placebo-controlled randomized trial. J Thromb Haemost 2014; 12 (04) 459-468
    CrossrefPubMedGoogle Scholar
  • 5 Chatterjee S, Chakraborty A, Weinberg I. et al. Thrombolysis for pulmonary embolism and risk of all-cause mortality, major bleeding, and intracranial hemorrhage: a meta-analysis. JAMA 2014; 311 (23) 2414-2421
    CrossrefPubMedGoogle Scholar
  • 6 Rivera-Lebron B, McDaniel M, Ahrar K. et al; PERT Consortium. Diagnosis, treatment and follow up of acute pulmonary embolism: consensus practice from the PERT consortium. Clin Appl Thromb Hemost 2019; 25: 1076029619853037
    CrossrefPubMedGoogle Scholar
  • 7 Jaff MR, McMurtry MS, Archer SL. et al; American Heart Association Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation, American Heart Association Council on Peripheral Vascular Disease, American Heart Association Council on Arteriosclerosis, Thrombosis and Vascular Biology. Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. Circulation 2011; 123 (16) 1788-1830
    CrossrefPubMedGoogle Scholar
  • 8 Konstantinides SV, Meyer G, Becattini C. et al; ESC Scientific Document Group. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J 2020; 41 (04) 543-603
    CrossrefPubMedGoogle Scholar
  • 9 Stevens SM, Woller SC, Baumann Kreuziger L. et al. Executive summary: antithrombotic therapy for VTE disease: second update of the CHEST guideline and expert panel report. Chest 2021; 160 (06) 2247-2259
    CrossrefPubMedGoogle Scholar
  • 10 Wang C, Zhai Z, Yang Y. et al; China Venous Thromboembolism (VTE) Study Group. Efficacy and safety of low dose recombinant tissue-type plasminogen activator for the treatment of acute pulmonary thromboembolism: a randomized, multicenter, controlled trial. Chest 2010; 137 (02) 254-262
    CrossrefPubMedGoogle Scholar
  • 11 Sharifi M, Bay C, Skrocki L, Rahimi F, Mehdipour M. “MOPETT” Investigators. Moderate pulmonary embolism treated with thrombolysis (from the “MOPETT” Trial). Am J Cardiol 2013; 111 (02) 273-277
    CrossrefPubMedGoogle Scholar
  • 12 Boone JD, Sherwani SS, Herborn JC, Patel KM, De Wolf AM. The successful use of low-dose recombinant tissue plasminogen activator for treatment of intracardiac/pulmonary thrombosis during liver transplantation. Anesth Analg 2011; 112 (02) 319-321
    CrossrefPubMedGoogle Scholar
  • 13 Aykan AC, Boyaci F, Hatem E. Successful treatment of a pulmonary embolism with low dose prolonged infusion of tissue typed plasminogen activator in a 37 year old female in early postoperative period. Anadolu Kardiyol Derg 2014; 14 (04) 400-402
    CrossrefPubMedGoogle Scholar
  • 14 Curtis GM, Lam SW, Reddy AJ, Bauer SR. Risk factors associated with bleeding after alteplase administration for pulmonary embolism: a case-control study. Pharmacotherapy 2014; 34 (08) 818-825
    CrossrefPubMedGoogle Scholar
  • 15 Kearon C, Akl EA, Ornelas J. et al. Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report. Chest 2016; 149 (02) 315-352
    CrossrefPubMedGoogle Scholar
  • 16 Mehta RH, Stebbins A, Lopes RD. et al. Race, bleeding, and outcomes in STEMI patients treated with fibrinolytic therapy. Am J Med 2011; 124 (01) 48-57
    CrossrefPubMedGoogle Scholar
  • 17 Eden SV, Meurer WJ, Sánchez BN. et al. Gender and ethnic differences in subarachnoid hemorrhage. Neurology 2008; 71 (10) 731-735
    CrossrefPubMedGoogle Scholar
  • 18 Zahuranec DB, Brown DL, Lisabeth LD. et al. Differences in intracerebral hemorrhage between Mexican Americans and non-Hispanic whites. Neurology 2006; 66 (01) 30-34
    CrossrefPubMedGoogle Scholar
  • 19 Schulman S, Kearon C. Subcommittee on Control of Anticoagulation of the Scientific and Standardization Committee of the International Society on Thrombosis and Haemostasis. Definition of major bleeding in clinical investigations of antihemostatic medicinal products in non-surgical patients. J Thromb Haemost 2005; 3 (04) 692-694
    CrossrefPubMedGoogle Scholar
  • 20 Zhang Z, Zhai ZG, Liang LR, Liu FF, Yang YH, Wang C. Lower dosage of recombinant tissue-type plasminogen activator (rt-PA) in the treatment of acute pulmonary embolism: a systematic review and meta-analysis. Thromb Res 2014; 133 (03) 357-363
    CrossrefPubMedGoogle Scholar
  • 21 Kiser TH, Burnham EL, Clark B. et al. Half-dose versus full-dose alteplase for treatment of pulmonary embolism. Crit Care Med 2018; 46 (10) 1617-1625
    CrossrefPubMedGoogle Scholar
  • 22 Wendelboe AM, Campbell J, Ding K. et al. Incidence of venous thromboembolism in a racially diverse population of Oklahoma County, Oklahoma. Thromb Haemost 2021; 121 (06) 816-825
    Article in Thieme ConnectPubMedGoogle Scholar
  • 23 Sane DC, Stump DC, Topol EJ. et al; The Thrombolysis and Angioplasty in Myocardial Infarction Study Group. Racial differences in responses to thrombolytic therapy with recombinant tissue-type plasminogen activator. Increased fibrin(ogen)olysis in blacks. Circulation 1991; 83 (01) 170-175
    CrossrefPubMedGoogle Scholar
  • 24 Berkowitz SD, Granger CB, Pieper KS. et al. Incidence and predictors of bleeding after contemporary thrombolytic therapy for myocardial infarction. The Global Utilization of Streptokinase and Tissue Plasminogen activator for Occluded Coronary Arteries (GUSTO) I Investigators. Circulation 1997; 95 (11) 2508-2516
    CrossrefPubMedGoogle Scholar
  • 25 Tang Y, Sampson B, Pack S. et al. Ethnic differences in out-of-hospital fatal pulmonary embolism. Circulation 2011; 123 (20) 2219-2225
    CrossrefPubMedGoogle Scholar
  • 26 Robertson L, Jones LE. Fixed dose subcutaneous low molecular weight heparins versus adjusted dose unfractionated heparin for the initial treatment of venous thromboembolism. Cochrane Database Syst Rev 2017; 2: CD001100
    PubMedGoogle Scholar
  • 27 Bagla S, Smirniotopoulos JB, van Breda A, Sheridan MJ, Sterling KM. Ultrasound-accelerated catheter-directed thrombolysis for acute submassive pulmonary embolism. J Vasc Interv Radiol 2015; 26 (07) 1001-1006
    CrossrefPubMedGoogle Scholar
  • 28 Patel N, Patel NJ, Agnihotri K. et al. Utilization of catheter-directed thrombolysis in pulmonary embolism and outcome difference between systemic thrombolysis and catheter-directed thrombolysis. Catheter Cardiovasc Interv 2015; 86 (07) 1219-1227
    CrossrefPubMedGoogle Scholar
  • 29 Aujesky D, Obrosky DS, Stone RA. et al. Derivation and validation of a prognostic model for pulmonary embolism. Am J Respir Crit Care Med 2005; 172 (08) 1041-1046
    CrossrefPubMedGoogle Scholar