1. pulmonary embolism protocol -- EMB review
Presenter R4 蔡一成 醫師
Supervisor MA 陳進明 醫師
Moderator 管仁澤 主任

5. Background
Thrombolytic therapy is usually reserved for patients with clinically serious or massive pulmonary embolism  thrombolytic agents may dissolve blood clot more rapidly than heparin and might reduce the death rate

6. Problem
Should we use thrombolytic therapy for all pulmonary embolism patients?
Do they have better outcome if patients use thrombolytic therapy?

7. P.I.C.O. P: Acute pulmonary embolism patients
I: Use thrombolytic therapy
C: Use anticoagulation therapy
O: Better outcome  survival rate with fewer complications

11. Grade of Recommendation Level of Evidence Therapy
Systemic review of RCTs 1b
Single RCT 1c
‘All-or-none’
[B] 2a
Systemic review of cohort studies 2b
Cohort study or poor RCT 2c
‘Outcomes’ research 3a
Systemic review of case-control studies 3b
Case-control study
[C] 4
Case series
[D] 5
Expert opinion, physiology, bench research

12. The Cochrane Database of Systematic Reviews
Thrombolytic therapy for pulmonary embolism
Author(s): Dong, Bi Rong; Yue, Jirong; Liu, Guan Jian; Wang, Qin; Wu, Taixiang
Issue:Volume (4), 2008,

13. Objectives
To assess the effectiveness and safety of thrombolytic therapy for patients with acute pulmonary embolism

14. Objectives (1) reduces the mortality rate with fewer complications;
(2) accelerates resolution of pulmonary emboli
(3) reduces the risk of recurrent pulmonary emboli
(4) may not increase the risk of bleeding during the scheduled treatment period

15. Methods Types of studies:
All randomised controlled trials that compared thrombolytic therapy with heparin alone or placebo or surgical intervention
Types of participants:
confirmed by pulmonary angiography or V/Q scan, or any other validated measurement
Types of outcome measures:
Primary outcomes
Secondary outcomes

16. Search Strategy
Cochrane Peripheral Vascular Diseases Group's Specialised Register
the Cochrane Central Register of Controlled Trials

17. Selection Criteria
Only studies classified A or B were eligible for inclusion in the systematic review
Category A - allocation concealment was adequately reported
Category B - allocation concealment was not described but it is mentioned in the text that the study was randomised

18. Results - 1
included the eight trials, with a total of 679 patients, in this review

19. Primary outcome measures
Death by all causes:
comparing thrombolytics versus heparin:
No statistically significant and both sets of 95% CI spanned 1.0 (OR 0.89; 95% CI 0.45 to 1.78)
Recurrence of pulmonary embolisms:
no statistically significant and both sets of 95% CI spanned 1.0 (overall OR 0.63; 95% CI 0.33 to 1.20)

20. Primary outcome measures
Haemorrhagic events:
(1) Major haemorrhagic events:
no statistically significant and both sets of 95% CI spanned 1.0 (OR 1.61; 95% CI 0.91 to 2.86)
(2) Minor haemorrhagic events:
more minor haemorrhagic events in the thrombolytics group but this was not statistically significant (OR 1.98; 95% CI 0.68 to 5.75)

21. Secondary outcome measures
Haemodynamic improvement and thrombolysis:
(1) Pulmonary arterial systolic pressure improvement:
statistical significance between the treatment and control groups (WMD mmHg; 95% CI to -4.20; WMD mmHg; 95% CI to -2.39, respectively)
thrombolytics may decrease pulmonary arterial systolic pressure

22. Secondary outcome measures
(2) Mean pulmonary arterial pressure improvement:
statistically significant (total WMD mmHg; 95% CI to -4.21)
the mean pulmonary arterial pressure decreased after treatment with thrombolytics

23. Secondary outcome measures
(3) Right ventricular end-diastolic pressure improvement:
Two studies showed contradictory results one study showed statistically significant
(4) Total pulmonary resistance improvement:
that urokinase improves total pulmonary resistance more than heparin

24. Secondary outcome measures
(5) Cardiac index improvement:
Two studies showed contradictory results one study showed statistically significant
(6) Other haemodynamic outcomes:
statistically significant improvements in right ventricular systolic pressure; right arterial mean pressure; arterial-venous oxygen difference; and arterial pO2

25. Secondary outcome measures
Perfusion lung scanning:
statistical significance was seen at day 30 after treatment
Pulmonary angiogram assessment:
the angiographic evidence was significantly greater in patients treated with thrombolytic therapy
Echocardiograms:
improved right-ventricular wall movement and tricuspid regurgitation

26. Discussion Thrombolytics for haemodynamic unstable patients
all the studies included in this review consisted of haemodynamically stable patients

27. Authors' conclusions
The currently available evidence is insufficient to show any definite benefit of thrombolytics over heparin in the treatment of acute pulmonary embolism

28. Thank you for your attention