Quelles indications pour la fibrinolyse dans l'embolie pulmonaire ?

Pulmonary embolism with shock carries a 25 to 50% mortality rate. Although no large randomised clinical trial is available, the results of a small controlled trial and some insights of a recently published meta-analysis suggest that thrombolysis decreases the mortality rate in these patients. In patients without clinical evidence of haemodynamic impairment, the mortality rate is much lower and does not justify more aggressive therapy other than anticoagulants. However, recent data suggest that among clinically stable patients, some may have a higher mortality risk. These so called sub-massive pulmonary embolism are defined either by right ventricular dysfunction assessed by echocardiography or by elevated troponin or brain natriuretic peptide. Meta-analysis of the 11 randomised controlled trials comparing fibrinolysis with heparin in such patients does not show a significant risk reduction in mortality with thrombolytic treatment. However, due to a lack of power, a substantial reduction in the mortality risk cannot be excluded. A large randomised controlled trial remains essential to resume the debate.