A reason to reduce expectations of thrombolytic therapy in pulmonary embolismBMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f1690 (Published 19 March 2013) Cite this as: BMJ 2013;346:f1690
- Sebastian Lucas, professor of pathology1
It is good to see pre-test probability and quantification of uncertainty being discussed regarding the clinical diagnosis of pulmonary thromboembolism.1 In my special interest area of maternal mortality and autopsy, I encounter many deaths after collapse in late pregnancy and delivery, where obstetric and emergency colleagues swear that “it has to be pulmonary embolism.” When pulmonary embolism is not seen at autopsy, the disappointed response is often “well, we broke it up with thrombolytic therapy.”
I am not aware of any published pathological research on the rate of disappearance of major clots in pulmonary arteries. But from first principles, a thrombus 1 cm or more wide cannot disintegrate under thrombolysis within a few hours. And I have seen one case of fatal massive pulmonary embolism where standard thrombolysis and 10 hours of subsequent care seemed to have had no effect on the size or consistency of the obstructing thrombus.
This is not an argument to restrict thrombolytic therapy, but perhaps a reason to reduce expectations.
Cite this as: BMJ 2013;346:f1690
Competing interests: None declared.