1 / 59

Thrombolytics for PE

Thrombolytics for PE. Stephen Akers, MD. Heparin for PE Barritt & Jordan 1960. 35 pt’s with clinical PE Acute RV failure Pulmonary Infarction. Barritt, Jordan Lancet 1960:1:1309. Barritt & Jordan 1960. 19 pt’s no treatment 16 pt’s IV heparin (36 hours) & coumadin (2 weeks .

adamdaniel
Download Presentation

Thrombolytics for PE

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Thrombolytics for PE Stephen Akers, MD

  2. Heparin for PE Barritt & Jordan 1960 • 35 pt’s with clinical PE • Acute RV failure • Pulmonary Infarction Barritt, Jordan Lancet 1960:1:1309

  3. Barritt & Jordan 1960 • 19 pt’s no treatment • 16 pt’s IV heparin (36 hours) & coumadin (2 weeks

  4. Barritt & Jordan 1960 • 5/19 untreated pt’s died of PE • 0/16 treated pt’s died a • p=.04

  5. Barritt & Jordan 1960 • 5/19 untreated pt’s non fatal recurrence • 0/16 treated pt’s non fatal recurrence

  6. Barritt & Jordan 1960 • Death and Recurrence • No Tx 10/19 • Tx 0/16 • p=.0005

  7. Barritt & Jordan 1960 • “Every patient who received the first injection of heparin survived.”

  8. Barritt & Jordan 1960 • Tx 38 additional pt’s • Death 0/38 • Recurrence 1/38

  9. Barritt & Jordan 1960 • Death, Recur in all (73) • No Tx 10/19 • Tx 1/54 • P=0.0000014!!

  10. Barritt & Jordan 1960 • No objective studies • Groups unmatched • Massive PE • Statistical methods

  11. Natural Hx • Hypoten >50% occlus • Shock > 80% occlus • Death < 1 hour

  12. Resolution PE • Mechanical Change • In vivo fibrinolysis • Partial within days • Complete within months

  13. Urokinase PE Trial (UPET) • 160 patients • Heparin 78- shock 5 • Urokinase 82- shock 9 JAMA Dec 21, 1970 Vol 214:2163

  14. UPET Inclusion • Compatible Clin Picture • PE within 5 days • PA gram segmental defect or greater

  15. UPET Protocol • 2,000 unit load • 2,000 unit/lb/hour • 12 hour infusion • Heparin

  16. UPET End Points • Pulm A gram • Right heart cath • V/Q scan

  17. UPET End Points • Before treatment • 6 to 18 hours post treatment

  18. UPET V/Q Scan • Five times first two weeks • Months 3, 6, 12

  19. Thrombolysis • Improved clot lysis • Improved hemodynm • Improved perfusion • Increased bleeding

  20. Bleeding • Heparin 27% • Uro/Strep 45% • Cut down sites for cath • One CNS bleed

  21. UPET no difference • Symptoms • Recurrence 15% v. 19% • Perfusion after day 5 • Mortality (6 vs. 5)

  22. Urokinase-Streptokinase PE Trial (USPET) • 59 urokin 12 hours • 54 urokin 24 hours • 54 streptokin 24 hours JAMA Sept 16, 1974 Vol 229:1606

  23. USPET no difference • Clot lysis • Hemodynamics • Reperfusion • Recurrence • Mortality

  24. Thrombolytics • Faster clot lysis • More bleeding • No improvement in clinical outcome

  25. DLCO Thrombolytics • Sub group UPET/USPET • Heparin 21 pt’s • Uro/Strepto 19 pt’s Sharma N Engl J Med 1980; 303:842

  26. Diffusing Capacity • Hep 2 wks 19 (69%) • Uro/Str 2 wks 22 (85%) • Hep 1 year 20 ((72%) • Uro/Str 1 year 24 (93%)

  27. DLCO Thrombolytics • Total diffusing capacity • Membrane diffusion • Pul/cap blood volume

  28. Membrane Diffusion • Hep 2 wks 52 • Uro/str 2 wks 47 • Hep 1 year 49 • Uro/Str 1 year 50

  29. Pulmonary-Capillary Blood Volume • Hep 2 weeks 30 • Uro/strep 2 weeks 45 • Hep 1 year 28 • Uro/Strep 1 year 49

  30. Thrombolytics DLCO • More complete resolution of pulm microthrombi • Clincal implications unclear

  31. Urokinase v. tPA • 45 Pt’s angio doc PE • tPA 22; 23 urokin • Clot lysis @ 2 hours • Perfusion @ 24 hours Goldhaber, et al Lancet 6 August 1988 293-298

  32. Urokinase v. tPA • tPA all pt’s full dose • Uro 9 pt’s stopped • bleeding 8 • allergic rx 1

  33. Urokinase v. TPA • Clot lysis @ 2 hours • tPA 82% • Uro 48% • p=0.008

  34. Urokinase v. TPA Perfusion @ baseline & 24 hours • tPA 59% to 71% • Uro 58% to 70% • no difference

  35. Urokinase v. TPA • Conclusions • tPA quicker lysis • tPA safer

  36. Additional tPA studies • Better lysis, less bleeding • Improved hemodyn • IV equiv to intrapulm

  37. tPA Levine Study • 68 pt’s PE on heparin • 33 tPA vs. 25 placebo • Q scan 24 hr, 7 days Levine, et al Chest 1990;98:1473-79

  38. tPA Levine Study • Improv perf @ 24 h • tPA 10% v placeb 5% • No improv perf @ 7 d • tPA 16% v placeb 11%

  39. tPA Goldhaber Study • 46 tPA v 55 heparin • Echo • Perfusion • Recurrence • Mortality Goldhaber, et al Lancet1993; 341:507-11

  40. tPA v Heparin • Improved echo • tPA 39% v heparin 17% • Improv’d perfusion • tPA 15% v heparin 2%

  41. tPA v Heparin • tPA • No death, no recurr • Heparin • 2 death, 3 recurr • p=0.06

  42. RV Dysfun in PE • Increased death • Despite absence of hypotension, shock Goldhaber, et al Lancet 1999;353:1386-8 Kasper, et al J AmColl Cardiol 1997;30:1165-71

  43. RV Dysfunction • Normal blood pressure • RV Dys 9% mortal • N’l RV 0.5% mortal

  44. Improvement in RV Dysfunction • t PA improves RV dysfunction acutely • RV function similar at one week hep or TPA

  45. tPA v Heparin Submassive PE • Hemo stable PE plus • RV dysfunction echo • Pul HTN echo or cath • RV strain EKG Konstantinides, et al NEJM 2002:347:1143

  46. Primary End Points • Primary • Death, escalation of Tx • Secondary • Recur PE, bleed, CVA

  47. Escalation of Tx • Wors’ng Sx’s (dyspnea) • Wors’ng respir failure • Wors’ng echo, cath • Hypotension

  48. Escalation of Tx • Catecholamines • Intubation, CPR • Embolectomy • Sec’dary thrombolysis

  49. Konstantinides, et al NEJM 2002:347:1143

  50. Konstantinides, et al NEJM 2002:347:1143

More Related