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Thrombolysis for Pulmonary Embolus: How Good Is It?

Not as good as heparin alone

A recent randomized trial of heparin alone versus alteplase plus heparin for treatment of submassive pulmonary embolism with right ventricular dysfunction demonstrated no difference in mortality, but the alteplase plus heparin group required fewer upgrades in level of care. The authors concluded that the reduced need for upgrades justifies the use of thrombolysis. Using data from that trial and other studies, researchers performed a cost-effectiveness analysis to assess the health and economic outcomes associated with thrombolytic therapy for pulmonary embolism.

They estimated from prior literature that the rate of intracranial hemorrhage was 3 times higher with alteplase plus heparin than with heparin alone (1.2% vs. 0.4%) and that the rate of other major bleeding complications was 4.2 times higher. The analysis showed that life expectancy (10.57 vs. 10.52 years) and quality-adjusted life-years (8.04 vs. 7.99) were slightly greater with heparin alone. Costs were slightly lower with heparin alone ($43,281 vs. $43,936). Various sensitivity analyses yielded essentially the same result, leading the authors to conclude that thrombolysis is less effective and more costly than heparin and that current evidence does not support use of thrombolysis in patients with acute pulmonary embolism and right ventricular dysfunction.

Comment: This study is akin to a meta-analysis, but the authors used complex decision theory, which is common in cost-effectiveness research. The take-home message is that traditional heparin therapy is at least as clinically effective, and as cost-effective, as use of alteplase plus heparin in pulmonary embolism with right ventricular dysfunction. Whether this extends to massive pulmonary embolism with shock is not yet known.

— J. Stephen Bohan, MD, MS, FACP, FACEP

Published in Journal Watch Emergency Medicine February 16, 2007

Citation(s):

Perlroth DJ et al. Effectiveness and cost-effectiveness of thrombolysis in submassive pulmonary embolism. Arch Intern Med 2007 Jan 8; 167:74-80.

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