Thrombolytic therapy for acute proximal pulmonary embolism without significant haemodynamic compromise

SummaryThrombolysis is indicated for patients with massive pulmonary embolism who are haemodynamically unstable. [ACCP Consensus Committee on Pulmonary Embolism. Opinions regarding the diagnosis and management of venous thrombo embolic disease. Chest 1996; 109:233–7; Goldhaber SZ, Haire WD, Feldstein ML, Miller M, Toltsiz R, Smith JL, et al. Alteplase versus heparin in acute pulmonary embolism: randomised trial assessing right ventricular function and pulmonary perfusion. Lancet 1993; 341:507–11] Its use in the management of patients who have proximal life threatening thrombus in the pulmonary vasculature without systemic hypotension is controversial [ACCP Consensus Committee on Pulmonary Embolism. Opinions regarding the diagnosis and management of venous thrombo embolic disease. Chest 1996; 109:233–7; Goldhaber SZ, Haire WD, Feldstein ML, Miller M, Toltsiz R, Smith JL, et al. Alteplase versus heparin in acute pulmonary embolism: randomised trial assessing right ventricular function and pulmonary perfusion. Lancet 1993; 341:507–11]. We describe three patients (two males aged 45 and 58 years) and one female (aged 44 years who was 25 weeks pregnant) with acute proximal pulmonary arterial embolism in the absence of systemic hypotension. Surgical embolectomy was considered but our clinical assessment was that the location and extent of the thrombus in each case justified thrombolytic therapy and subsequently heparinisation even though no patient had evidence of systemic hypotension. Each patient was successfully treated with streptokinase (250,000 iu intravenously over 30 min followed by 100,000 iu per h intravenously for 12–24 h). Warfarin was commenced in two patients to achieve a target INR of 3–4 and low molecular weight heparin was continued throughout the remainder of her pregnancy in the third patient. Follow-up pulmonary angiography showed complete resolution of thrombus and there was improvement in 2D echocardiographic appearance. The pregnant lady delivered a healthy baby, normally, at term. In one patient who is now 6 months post-thrombolysis, repeat estimate of pulmonary vascular resistance and 2D echocardiography was normal at 6 months. We suggest that patients with potentially fatal pulmonary emboli should be considered for thrombolytic therapy even if they do not demonstrate haemodynamic instability.