Published online before print July 19, 2004, doi: 10.1161/01.CIR.0000137826.09715.9C
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(Circulation. 2004;110:744-749.)
© 2004 American Heart Association, Inc.
Original Articles |
Thrombolysis Compared With Heparin for the Initial Treatment of Pulmonary Embolism
A Meta-Analysis of the Randomized Controlled Trials
From the School of Medicine and Pharmacology, University of Western Australia (S.W., J.W.E.), Perth, West Australia; Department of Radiology (D.J.Q.), King’s College Hospital, London, UK; and Department of Internal Medicine (G.A.), University of Perugia, Perugia, Italy.
Correspondence to Dr John W. Eikelboom, Department of Haematology, Royal Perth Hospital, Wellington Street, Perth, West Australia 6001. E-mail john.eikelboom{at}health.wa.gov.au
Received January 16, 2004; de novo received February 9, 2004; revision received May 4, 2004; accepted May 7, 2004.
Background— Randomized trials and meta-analyses have reached conflicting conclusions about the role of thrombolytic therapy for the treatment of acute pulmonary embolism.
Methods and Results— We performed a meta-analysis of all randomized trials comparing thrombolytic therapy with heparin in patients with acute pulmonary embolism. Eleven trials, involving 748 patients, were included. Compared with heparin, thrombolytic therapy was associated with a nonsignificant reduction in recurrent pulmonary embolism or death (6.7% versus 9.6%; OR 0.67, 95% CI 0.40 to 1.12, P for heterogeneity=0.48), a nonsignificant increase in major bleeding (9.1% versus 6.1%; OR 1.42, 95% CI 0.81 to 2.46), and a significant increase in nonmajor bleeding (22.7% versus 10.0%; OR 2.63, 95% CI 1.53 to 4.54; number needed to harm=8). Thrombolytic therapy compared with heparin was associated with a significant reduction in recurrent pulmonary embolism or death in trials that also enrolled patients with major (hemodynamically unstable) pulmonary embolism (9.4% versus 19.0%; OR 0.45, 95% CI 0.22 to 0.92; number needed to treat=10) but not in trials that excluded these patients (5.3% versus 4.8%; OR 1.07, 95% CI 0.50 to 2.30), with significant heterogeneity between these 2 groups of trials (P=0.10).
Conclusions— Currently available data provide no evidence for a benefit of thrombolytic therapy compared with heparin for the initial treatment of unselected patients with acute pulmonary embolism. A benefit is suggested in those at highest risk of recurrence or death. The number of patients enrolled in randomized trials to date is modest, and further evaluation of the efficacy and safety of thrombolytic therapy for the treatment of high-risk patients with acute pulmonary embolism appears warranted.
Key Words: embolism • meta-analysis • thrombolysis • heparin
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