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Update in Hospital Medicine
- Andrew D. Auerbach, MD, MPH; and
- Jennifer Kleinbart, MD
- From the University of California, San Francisco, San Francisco, California, and Emory University, Atlanta, Georgia.
2003–2004 Series: Update Sessions from ACP's 2003 Annual Session
The articles chosen for this update cover topics important for general internists with active inpatient practices. These original research papers published in 2002 gave new insights into common inpatient diagnoses and frequent challenges for inpatient physicians. The articles were identified through MEDLINE searches and review journals, such as ACP Journal Club and Journal Watch. Local and national experts were polled to help prioritize the list and highlight the work with the highest perceived impact. These papers question several conventional practices in inpatient medicine or point the direction into which the field may be heading.
Pulmonary Diseases
Alteplase Should Be Used More Often for Pulmonary Embolism
Investigators asked whether the outcome of patients with submassive pulmonary embolism (PE) could be improved with thrombolytic therapy. The authors randomly assigned patients with PE diagnosed by ventilation–perfusion scanning, computed tomography (CT), or pulmonary angiography. Patients also had right ventricular dysfunction or pulmonary hypertension noted on echocardiography or electrocardiographic changes consistent with right ventricular strain or failure. Excluded patients were older than 80 years of age, were hemodynamically unstable, or had a contraindication to thrombolytic therapy. The primary outcome was a composite end point representing the failure of thrombolysis (for example, need for vasopressors, additional thrombolytics, and embolectomy), as well as such clinical outcomes as cardiopulmonary resuscitation, intubation, or death. The authors also studied secondary outcomes such as bleeding complications and recurrent PE.
A total of 256 patients from several European centers were randomly assigned, 138 were treated with unfractionated intravenous heparin alone, and 118 were treated with heparin and alteplase administered as a 10-mg intravenous bolus followed by 90 mg over 2 hours. Intravenous anticoagulation was continued in both groups for 3 days, and then patients began warfarin therapy. Outcomes were tabulated for the subsequent 30 days. The 2 groups were well matched, and an …
