Review article



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Fibrinolytic therapy in pulmonary embolism

Brady WJ

Seth Althoff. Virginia Medical Centre. EE.UU.

There is reasonable evidence that suggests that fibrinolytic therapy accelerates the
resolution of PE while simultaneously reducing the recurrence of pulmonary embolism; it
can also improve other parameters, such as pulmonary blood flow, lung perfusion, and
right ventricular dysfunction. Unfortunately, conclusive evidence demonstrating a
mortality reduction is not found in the literature, particularly in those patients who are
clinically stable with intermediate to low risk of death. The clinician should assess the
mortality risk of the PE relative to both the potential benefits and the adverse effects of
fibrinolytic therapy for cardiac arrest and the various risk group presentations. In cardiac
arrest related to PE, there are no contraindications to medical fibrinolysis; fibrinolytic
therapy likely offers the reasonable chance at survival. In those patients not in cardiac
arrest, a categorization into high, intermediate, and low risk groups will aid in decision
making. In the absence of significant bleeding risk, those patients who are
hemodynamically unstable or have signs of right ventricular dysfunction would likely
benefit from fibrinolytic agents – i.e., the high risk group. Intermediate risk presentations
demonstrate less benefit such that the consideration of complications not infrequently
outweighs fibrinolytic advantage. The literature is mixed, however, in its
recommendations for the intermediate group. And, lastly, the low risk group does not
benefit from fibrinolysis. Despite this categorization, the decision to administer a
fibrinolytic agent remains challenging; the clinician must consider the risks of PE coupled
with the risks of fibrinolysis, as compared with this medication’s potential benefit. The
decision to administer a fibrinolytic agent in the setting of PE remains highly individual
and is most appropriately addressed by the clinician at the bedside.

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