What is the patient's history of thrombolytic therapy?

From the Guidelines

The patient's history of thrombolytic therapy is likely to be associated with a high-risk pulmonary embolism (PE) diagnosis, where the benefits of treatment outweigh the risks.

Thrombolytic Therapy for PE

• The use of thrombolytics for patients with PE and hemodynamic compromise may reduce mortality, with a relative risk (RR) of 0.61 and an absolute risk reduction (ARR) of 13 fewer per 1000 patients 1.
• Thrombolytic therapy can rapidly resolve thromboembolic obstruction and exert beneficial effects on haemodynamic parameters, with approximately 92% of patients classified as responders to thrombolysis based on clinical and echocardiographic improvement within the first 36 hours 1.

Approved Thrombolytic Regimens

• Approved thrombolytic regimens for pulmonary embolism include:
  • Streptokinase: 250,000 IU as a loading dose over 30 minutes, followed by 100,000 IU/h over 12-24 hours
  • Urokinase: 4400 IU/kg as a loading dose over 10 minutes, followed by 4400 IU/kg/h over 12-24 hours
  • rtPA: 100 mg over 2 hours or 0.6 mg/kg over 15 minutes (maximum dose 50 mg) 1

Risks and Contraindications

• Thrombolytic therapy carries a significant risk of bleeding, especially when predisposing conditions or comorbidities exist, with a cumulative rate of major bleeding of 13% and a rate of intracranial/fatal haemorrhage of 1.8% 1.
• Contraindications to thrombolysis that are considered absolute in acute myocardial infarction may become relative in a patient with immediately life-threatening, high-risk PE 1.

Clinical Guidelines

• The American Society of Hematology (ASH) guideline panel provides a strong recommendation in favor of the use of thrombolytic therapy for patients with PE and hemodynamic compromise 1.
• The European Society of Cardiology (ESC) guidelines recommend considering thrombolytic therapy in hemodynamically unstable patients with a high clinical suspicion for PE for whom the diagnosis of PE cannot be confirmed in a timely manner 1.

From the Research

History of Thrombolytic Therapy

• The discovery of thrombolytic agents dates back to the 1930s, with the recognition of substances that could activate the fibrinolytic system 2.
• The first use of thrombolytic therapy in acute ischemic stroke was described in 1958, but it was not until the 1980s that thrombolytic therapy became a standard treatment for acute myocardial infarction 3, 4.
• The development of recombinant human tissue plasminogen activator (tPA) and other thrombolytic agents has improved the treatment of acute myocardial infarction and acute ischemic stroke 3, 2.

Evolution of Thrombolytic Therapy

• Thrombolytic therapy has undergone significant changes over the years, with the introduction of new agents and the development of more effective treatment strategies 5, 6.
• The use of thrombolytic therapy has expanded beyond acute myocardial infarction and acute ischemic stroke, with potential applications in other conditions such as acute limb ischemia 6.
• Despite the advancements in thrombolytic therapy, bleeding complications remain a major risk, and the development of more effective and safer agents is an ongoing area of research 2, 6.

Current Status of Thrombolytic Therapy

• Thrombolytic therapy remains an important treatment option for acute myocardial infarction and acute ischemic stroke, particularly in patients who do not have access to primary percutaneous coronary intervention (PCI) 5.
• The current use of thrombolytic therapy is guided by evidence-based guidelines, which take into account the patient's clinical presentation, medical history, and other factors 3, 2.
• Ongoing research is focused on developing new thrombolytic agents and improving the safety and efficacy of existing treatments, with the goal of reducing morbidity and mortality in patients with cardiovascular disease 2, 5.