Daily Bolus of LR: Fibrinolysis in PE

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October 31, 2011 by dailybolusoflr

Fibrinolysis in PE

Thanks to our guest author. . Tiffany Fong, MD!

Which patients with an acute PE should be treated with fibrinolysis?

1) It is “reasonable” to give to patients with massive acute PE and acceptable risk of bleeding complications. (Class IIa, Level of Evidence B)

Massive PE is defined as acute PE with at least one of the following:

o Sustained hypotension caused by the PE (SBP <90 for ≥15 min, or requiring inotropic support)
o Pulselessness

o Persistent profound bradycardia (HR <40 with signs/sx of shock)

2) “Consider giving” to patients with submassive acute PE with clinical evidence of adverse prognosis and with low risk of bleeding complications. (Class IIb, Level of Evidence C)

Submassive PE is defined as PE without systemic hypotension (SBP ≥90), but with either RV dysfunction or myocardial necrosis.

RV dysfunction is defined as:

1. RV dilation or RV systolic dysfunction on echo
2. RV dilation on CT
3. BNP >90 or pro-BNP >500
4. EKG changes (new complete or incomplete RBB, anteroseptal ST elevation or depression, or anteroseptal T wave inversion)

Myocardial necrosis is defined as troponin I>0.4 or troponin T>0.1

Clinical evidence of adverse prognosis is defined by new hemodynamic instability, worsening respiratory insufficiency, severe RV dysfunction, or major myocardial necrosis

3) Fibrinolysis is NOT recommended in :

· Low-risk PE (i.e. anything that does not meet the definition of massive or submassive PE)

· Undifferentiated cardiac arrest

(Class III, Level of Evidence B)

Recommendation for fibrinolysis is:
Alteplase 100mg infused through a peripheral IV over 2 hours
Hold anticoagulation during the 2 hour infusion period

Ref: Jaff MR et al Management of massive and submassive PE, iliofemoral DVT, and chronic thromboembolic pulmonary HTN: a scientific statement from the AHA. Circulation. 2011;123:1788-1830
http://circ.ahajournals.org/content/123/16/1788.full

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