LETTER
Risks for Bleeding in Patients with Pulmonary Embolism Treated with Thrombolytic Agents
Bimal P. Jain
15 April 1995 | Volume 122 Issue 8 | Pages 630-632
TO THE EDITOR:
I suggest that only major bleeding at catheter insertion sites and not at other sites, such as intracerebral or retroperitoneal sites, be considered a complication of pulmonary angiography in patients receiving thrombolytic therapy. The reported risk for this complication would therefore be 10.6% (7 of 66 patients) and not 14% (18 of 129 patients) as calculated by Stein and colleagues [1]. To avoid this complication, they recommend giving thrombolytic therapy without pulmonary angiography if the calculated frequency (probability) of pulmonary embolism from clinical and lung scan evaluation is higher than 21%. I find this recommendation clinically unacceptable, as shown by the following example.
A patient has a 30% probability of pulmonary embolism on the basis of a high clinical likelihood and a low-probability lung scan [2]. He has a relatively high (70%) probability of not getting any benefit from thrombolytic therapy. However, if he receives thrombolytic therapy, he would have a 4.2% risk for major internal bleeding, which could be fatal if it is intracerebral [3]. In such a situation, a pulmonary angiogram seems more appropriate. If the angiogram result is negative, we would not give thrombolytic therapy and thus would avoid the 4.2% risk for potentially fatal major bleeding. If the result is positive, we would use thrombolytic therapy because we know it will benefit the patient. The 10.6% additional risk for major bleeding at a catheter insertion site is acceptable because this bleeding, if it occurs, is not fatal and can be treated easily with local pressure and blood transfusions.
I believe a more rational approach to minimizing major bleeding at catheter insertion sites is the use of a superficial vein of the arm for catheterization, as suggested by the authors, or the use of a single-bolus thrombolytic regimen [4].
1. Stein PD, Hull RD, Raskob G. Risks for major bleeding from thrombolytic therapy in patients with acute pulmonary embolism. Consideration of noninvasive management. Ann Intern Med. 1994; 121:313-7.
2. The PIOPED Investigators. Values of the ventilation/perfusion scan in acute pulmonary embolism. Results of the Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED). JAMA. 1990; 263:2753-9.
3. Dalla-Volta S, Palla A, Santolicandro A, Guntini C, Pengo V, Visioli O, et al. PALMS-2: Alteplase combined with heparin versus heparin in the treatment of acute pulmonary embolism. Plasminogen Activator Italian Multicenter 2. J Am Coll Cardiol. 1992; 20:520-6.
4. Levine M, Hirsh J, Cruickshank M, Neemech J, Turpie AG, et al. A randomized trial of a single bolus dosage regimen of recombinant tissue plasminogen activator in patients with acute pulmonary embolism. Chest. 1990; 98:1473-9.
About Letters
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
Top
References
Article
