Thrombolytic therapy and interventional procedures for pulmonary embolism
All patients with pulmonary embolism (PE) should be assessed for the risk of death from PE.
Haemodynamically unstable patients (eg cardiac arrest, shock, persistent hypotension) are considered at high risk of death from PEKahn, 2022. If haemodynamically unstable patients with PE have a low bleeding risk, systemic thrombolytic therapy should be strongly considered to reduce thrombus burden. Other options include catheter-directed thrombolytic therapy, aspiration thrombectomy and surgical thrombectomy; use of these treatments depends on local availability and expertise. Consult a multidisciplinary pulmonary embolism response team (PERT), if available. For haemodynamically unstable patients with a high bleeding risk, seek specialist adviceKonstantinides, 2020.
Patients with evidence of right ventricular dysfunction and elevated cardiac troponin concentration without systemic hypotension are considered at intermediate risk of death from PE. Although patients at intermediate risk of death from PE can be managed with anticoagulation alone, selected cases may benefit from catheter-directed thrombolytic therapy; seek specialist adviceKahn, 2022Konstantinides, 2020.
Patients without evidence of right ventricular dysfunction are considered at low risk of death from PE and can be managed with anticoagulation aloneKahn, 2022.
Thrombolytic therapy increases the bleeding risk (particularly intracranial), especially in advanced age (eg older than 75 years)Konstantinides, 2020. Ensure that the patient does not have any contraindications to thrombolytic therapy—for information on absolute and relative contraindications to thrombolytic therapy, see the European Society of Cardiology (ESC) Guidelines for the diagnosis and management of acute pulmonary embolism.
Consult a local protocol for systemic thrombolytic therapy for the management of PE. If a local protocol is not available, suitable regimens are1Kahn, 2022:
1alteplase alteplase alteplase alteplase
65 kg or more: 10 mg intravenously as an initial dose, followed by 90 mg by intravenous infusion over 2 hours
less than 65 kg: 1.5 mg/kg total dose, given as 10 mg intravenously as an initial dose, followed by the remainder of the dose by intravenous infusion over 2 hours
high risk of bleeding (eg advanced age): 10 mg intravenously as an initial dose, followed by 40 mg by intravenous infusion over 1 hour. A further dose of alteplase may be given based on clinical response (maximum 1.5 mg/kg total dose in patients less than 65 kg)Kearon, 2016Konstantinides, 2014Sharifi, 2013
OR
1tenecteplase tenecteplase tenecteplase tenecteplase
less than 60 kg: 30 mg (6000 units) intravenously
60 to 69 kg: 35 mg (7000 units) intravenously
70 to 79 kg: 40 mg (8000 units) intravenously
80 to 89 kg: 45 mg (9000 units) intravenously
90 kg or more: 50 mg (10 000 units) intravenously.
Following thrombolytic therapy, in patients with high-risk PE, start a parenteral anticoagulant when the patient’s activated partial thromboplastin time (APTT) is less than twice the upper limit of normal. Suitable regimens for low molecular weight heparin (LMWH) are:
1dalteparin (CrCl 30 mL/min or more) 200 units/kg subcutaneously, once daily, or 100 units/kg twice daily2 dalteparin dalteparin dalteparin
OR
1enoxaparin enoxaparin enoxaparin enoxaparin
CrCl 30 mL/min or more: 1.5 mg/kg subcutaneously, once daily, or 1 mg/kg twice daily
CrCl less than 30 mL/min: 1 mg/kg subcutaneously, once daily.
If dalteparin is required for a patient with a CrCl of less than 30 mL/min, seek expert advice. The twice-daily dosage regimen of dalteparin or enoxaparin may be preferred for patients at high risk of bleeding, such as patients who are older, are at extremes of weight (eg 150 kg or over) or have cancer. See also Considerations for anticoagulation of patients with obesity (if applicable) and Practical information on using low molecular weight heparin for more information, including management of bleeding.
Alternatively, unfractionated heparin (UFH) is used for patients with severe kidney impairment or for those who have a high risk of bleeding (eg pulmonary infarction) that may require rapid reversal of anticoagulation.
Dose unfractionated heparin according to a local protocol. If a local protocol is not available, use:
unfractionated heparin 18 units/kg/hour by intravenous infusion, adjusted according to APTT. unfractionated heparin heparin, unfractionated heparin, unfractionated
No loading dose of unfractionated heparin is necessary. Consult a local protocol for activated partial thromboplastin time (APTT) target values or seek specialist haematologist advice.
See Practical information on using unfractionated heparin for more information, including management of bleeding.