Transforming and Simplifying the Treatment of Pulmonary Embolism: Safe Dose Thrombolysis Plus New Oral Anticoagulants

Administration of systemic thrombolysis in pulmonary embolism (PE) has been limited to severe forms due to the risk of intracerebral hemorrhage (ICH). There is growing evidence from small studies that low-dose systemic thrombolysis has equal efficacy to standard dose, while eliminating the risk of ICH. Little data exists on the combined use of low-dose systemic thrombolysis and new oral anticoagulants (NOAC). We evaluated the clinical and echocardiographic outcome of patients treated with low or safe dose thrombolysis (SDT) and NOAC at intermediate term. We retrospectively identified 159 patients with massive and submassive PE who were treated with SDT and NOAC over a 2-year period by our group. They were followed prospectively for PE-related mortality, recurrent PE, bleeding, change in right/left ventricle (RV/LV) size, pulmonary artery systolic pressure (PASP), and clinical improvement at a mean follow-up of 18 +/- A 3 months. At 6 months, the RV/LV size was reduced from 1.29 +/- A 0.28 to 0.89 +/- A 0.03 (p < 0.001). The PASP dropped from 53.12 +/- A 3.85 mmHg to 30.39 +/- A 3.93 mmHg (p < 0.001). There was no ICH or in-hospital major or minor bleeding. At 18 months, three patients died of cancer. Recurrent PE developed in one patient who had been later switched to warfarin. The duration of hospitalization was 1.8 +/- A 0.3 days. With combination of SDT and NOAC, treatment of massive and submassive PE becomes identical and is transformed from an anticoagulation first to a thrombolysis first approach, thereby making treatment streamlined, simple, safe and effective, accessible and inexpensive.