Risks for major bleeding from thrombolytic therapy in patients with acute pulmonary embolism. Consideration of noninvasive management

• Published in: Annals of internal medicine Vol. 121; no. 5; p. 313
• Main Authors: Stein, P D, Hull, R D, Raskob, G
• Format: Journal Article
• Language: English
• Published: United States 01.09.1994
• Subjects: Acute Disease; Angiography - adverse effects; Decision Support Techniques; Hemorrhage - chemically induced; Humans; Pulmonary Embolism - diagnostic imaging; Pulmonary Embolism - drug therapy; Risk Factors; Thrombolytic Therapy - adverse effects; Tissue Plasminogen Activator - adverse effects; Ventilation-Perfusion Ratio
• ISSN: 0003-4819
• DOI: 10.7326/0003-4819-121-5-199409010-00001

To assess the relative risks for bleeding with thrombolytic therapy in patients who are managed using pulmonary angiograms compared with those managed using noninvasive tests, primarily the ventilation-perfusion lung scan. A decision analysis based on data from other studies. The risk for major bleeding in patients with pulmonary embolism who receive thrombolytic therapy after a noninvasive diagnosis was assessed from complications of thrombolytic therapy in patients with myocardial infarction, assuming that the same risk ratio for major bleeding when comparing an invasive with a noninvasive approach applied to patients with pulmonary embolism. The risk ratio was 3.3 (95% CI, 1.5 to 9.8) for major bleeding in patients with myocardial infarction. One or more major complications of pulmonary angiography occurred in 1.3% of patients (CI, 0.6% to 1.9%). The average reported risk was 14% (18 of 129 patients) (CI, 7.9% to 20.1%) for major bleeding in patients who had pulmonary angiography before receiving tissue plasminogen activator (tPA). The estimated risk was 4.2% (estimated CI, 1.4% to 9.3%) for major bleeding with tPA after a noninvasive diagnosis of pulmonary embolism. Assuming a risk of 1.3% for major complications from pulmonary angiography, a risk for major hemorrhage of 14.0% for an invasive diagnosis, and a risk of 4.2% for a noninvasive diagnosis, fewer complications would occur with noninvasive management if the prevalence of pulmonary embolism exceeded 21%. Among patients with suspected pulmonary embolism who are candidates for thrombolytic therapy, it is safer to use noninvasive diagnostic tests in many patients.