Thrombolysis in Pulmonary Embolism

  • Carlos Jerjes-SánchezEmail author


We analyzed a large series that included 289 patients with proven extensive PE complicated with severe pulmonary arterial hypertension and right ventricular dysfunction; high dose and short-term of first generation thrombolytic and recombinant human tissue-type plasminogen activator infusion by peripheral vein, also tenecteplase-tissue-type plasminogen activator were effective and safe. In terms of residual thrombosis, second and third generation fibrinolytics had better results as emergency procedures. In our series mortality and bleeding complications were low. A possible explanation could include younger age, fast-track thrombolysis in Emergency Department, the avoidance of venous puncture, and the fact that physicians involved in-patient care had significant experience in thrombolysis in other medical situations. In a long-term follow-up postthrombotic syndrome was the most frequent and important complication.


Thrombolysis Alteplase Streptokinase Right ventricular dysfunction 


  1. 1.
    Jerjes-Sánchez C, Ramírez RA, Arriaga NR, Pimentel MG. Dosis altas e infusión rápida de estreptoquinasa para el tratamiento de tromboembolia pulmonar masiva. Arch Inst Cardiol Mex. 1993;63:227–34.PubMedGoogle Scholar
  2. 2.
    Ozbeck C, Sen S, Frank S, Dyckmans J, Schieffer H. Rapid high dose streptokinase in severe pulmonary embolism. Lancet. 1989;334:229–30.CrossRefGoogle Scholar
  3. 3.
    Jerjes-Sanchez C, Gutierrez-Fajardo P, Ramirez-Rivera A, Garcia ML, Hernández CHG. Infarto agudo del ventrículo derecho secundario a tromboembolia pulmonar masiva. Arch Inst Cardiol Mex. 1995;65:65–73.PubMedGoogle Scholar
  4. 4.
    Dack S, Master AM, Horn H, Grishman A, Field LE. Acute coronary insufficiency due to pulmonary embolism. Am J Med. 1949;7:464–77.CrossRefPubMedGoogle Scholar
  5. 5.
    Jerjes-Sanchez C, Ramirez-Rivera A, Garcia ML, Arriaga-Nava R, Valencia-Sanchez S, Rosado-Buzzo A, Pierzo JA, Rosas ME. Streptokinase and heparin versus heparin alone in massive pulmonary embolism: a randomized controlled trial. J Thromb Thrombolysis. 1995;2:67–9.CrossRefGoogle Scholar
  6. 6.
    Jerjes-Sanchez C, Ramirez-Rivera A, Arriaga-Nava R, Iglesias-Gonzalez S, Gutierrez P, Ibarra-Perez C, Martinez A, Valencia S, Rosado-Buzzo A, Pierzo JA, Rosas E. High dose and short-term streptokinase infusion in patients with pulmonary embolism. Prospective with seven-year follow-up trial. J Thromb Thrombolysis. 2001;12:237–47.CrossRefPubMedGoogle Scholar
  7. 7.
    Goldhaber SZ. Thrombolysis in pulmonary embolism: a debatable indication. Thromb Haemost. 2001;86:444–51.PubMedGoogle Scholar
  8. 8.
    Meneveau N, Schiele F, Metz D, Valette B, Attali P, Vuillemenot A. Comparative efficacy of a two-hour regimen of streptokinase versus alteplase in acute massive pulmonary embolism: Immediate clinical and hemodynamic outcome and one-year follow-up. J Am Coll Cardiol. 1998;31:1057–63.CrossRefPubMedGoogle Scholar
  9. 9.
    Tebbe U, Graf A, Kamke W, Zahn R, Forycki F, Kratzsch G, Günther B. Hemodynamic effects of double-bolus reteplase versus alteplase infusion in massive pulmonary embolism. Am Heart J. 1999;138:39–44.CrossRefPubMedGoogle Scholar
  10. 10.
    Ramirez-Rivera A, Gutierrez-Fajardo P, Jerjes-Sanchez C, Hernandez-Chavez G. Acute right myocardial infarction without significant obstructive coronary lesions secondary to massive pulmonary embolism. Chest. 1993;104:80S.Google Scholar
  11. 11.
    Sharma GVRK, Folland ED, McIntyre KM, Sasahara AA. Long-term benefit of thrombolytic therapy in patients with pulmonary embolism. Vasc Med. 2000;5:91–5.CrossRefPubMedGoogle Scholar
  12. 12.
    Riveiro A, Lindmarker P, Johnsson H, Juhlin-Dannfelt A, Jorfeldt L. Pulmonary embolism: one year follow-up with echocardiography Doppler and five-year survival analysis. Circulation. 1999;99:1325–30.CrossRefGoogle Scholar
  13. 13.
    Konstantinides S, Geibel A, Heusel G, Heinrich F, Kasper W. Heparin plus alteplase compared with heparin alone in patients with submassive pulmonary embolism. N Engl J Med. 2002;347:1143–50.CrossRefPubMedGoogle Scholar
  14. 14.
    Meneveau N, Mingb LP, Seronde MF, Mersina N, Schielea F, Caulfield F, Bernard Y, Bassand JP. In-hospital and long-term outcome after sub-massive and massive pulmonary embolism submitted to thrombolytic therapy. Eur Heart J. 2003;24:1447–54.CrossRefPubMedGoogle Scholar
  15. 15.
    Goldhaber SZ, Come PC, Lee RT, Brauwald LT, Parker JA, Haire WD, Feldstein ML, Miller M, Toltzis R, Smith JL, Taveira de Silva AM, Mogtader A, McDonough TJ. Alteplase versus heparin in acute pulmonary embolism; randomized trial assessing right-ventricular function and pulmonary perfusion. Lancet. 1993;341:507–11.CrossRefPubMedGoogle Scholar
  16. 16.
    Podbregar M, Krivec B, Voga G. Impact of morphologic characteristics of central pulmonary thromboemboli in massive pulmonary embolism. Chest. 2002;122:973–9.CrossRefPubMedGoogle Scholar
  17. 17.
    Recommendations for a standardized report for adult transthoracic echocardiography: a report from the American Society of Echocardiography’s Nomenclature and Standards Committee and Task Force for a Standardized Echocardiography Report. JASE. 2002;15:275–90.Google Scholar
  18. 18.
    Smeeth L, Cook C, Thomas S, Hall AJ, Hubbard R, Vallance P. Risk of deep vein thrombosis and pulmonary embolism after acute infection in a community setting. Lancet. 2006;367:1075–9.CrossRefPubMedGoogle Scholar
  19. 19.
    Jerjes-Sanchez C. Venous and arterial thrombosis. A continuum spectrum of the same disease? Eur Heart J. 2005;26:1–2.CrossRefGoogle Scholar
  20. 20.
    Prandoni P, Bilora F, Marchiori A, Bernardi E, Peitrobeli F, Lensing AWA, Prins MH, Girolami A. An association between atherosclerosis and venous thrombosis. N Engl J Med. 2003;348:1435–41.CrossRefPubMedGoogle Scholar
  21. 21.
    Becattini C, Agnelli G, Prandoni P, Silingardi M, Salvi R, Taliani MR, Poggio R, de Imberti D, Ageno W, Pogliani E, Porro F, Casazza F. A prospective study on cardiovascular events after acute pulmonary embolism. Eur Heart J. 2005;26:77–83.CrossRefPubMedGoogle Scholar
  22. 22.
    Libby P, Crea F. Clinical implications of inflammation for cardiovascular primary prevention. Eur Heart J. 2010;31:777–83.CrossRefPubMedGoogle Scholar
  23. 23.
    Libby P, Ridker PM, Hansson GK, for the Leducq Transatlantic Network on Atherothrombosis. Inflammation in atherosclerosis: from pathophysiology to practice. J Am Coll Cardiol. 2009;54:2129–38.CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Glynn RJ, Danielson E, Fonseca FA, Genest J, Gotto Jr AM, Kastelein JJ, Koenig W, Libby P, Lorenzatti AJ, MacFadyen JG, Nordestgaard BG, Shepherd J, Willerson JT, Ridker PM. A randomized trial of rosuvastatin in the prevention of venous thromboembolism. N Engl J Med. 2009;360:1851–61.CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Piazza G, Goldhaber ZS. Venous thromboembolism and atherothrombosis. An integrated approach. Circulation. 2010;121:2146–50.CrossRefPubMedGoogle Scholar
  26. 26.
    Goldhaber ZS. Risk factors for venous thromboembolism. J Am Coll Cardiol. 2010;56:1–7.CrossRefPubMedGoogle Scholar
  27. 27.
    Stevinson BG, Hernandez-Nino J, Rose G, Kline JA. Echocardiographic and functional cardiopulmonary problems 6 months after first-time pulmonary embolism in previously healthy patients. Eur Heart J. 2007;28:2517–24.CrossRefPubMedGoogle Scholar
  28. 28.
    Lualdi JC, Goldhaber SZ. Right ventricular dysfunction after acute pulmonary embolism: pathophysiologic factors, detection, and therapeutic implications. Am Heart J. 1995;130:1276–82.CrossRefPubMedGoogle Scholar
  29. 29.
    Kucher N, Rossi E, De Rosa M, Goldhaber SZ. Prognostic role of echocardiography among patients with acute pulmonary embolism and a systolic arterial pressure of 90 mm hg or higher. Arch Intern Med. 2005;165:1777–81.CrossRefPubMedGoogle Scholar
  30. 30.
    Grifoni S, Vanni S, Magazzini S, Olivotto I, Conti A, Zanobetti M. Association of persistent right ventricular dysfunction at hospital discharge after acute pulmonary embolism with recurrent thromboembolic events. Arch Intern Med. 2006;166:2151–6.CrossRefPubMedGoogle Scholar
  31. 31.
    Goldhaber SZ. Assessing the prognosis of acute pulmonary embolism. Chest. 2008;133:334–6.CrossRefPubMedGoogle Scholar
  32. 32.
    Riveiro A, Lindmarker P, Juhlin-Dannfelt A, Johnson H, Jorfeldt L. Echocardiography Doppler in pulmonary embolism: right ventricular dysfunction as predictor of mortality. Am Heart J. 1997;134:479–87.CrossRefGoogle Scholar
  33. 33.
    Kasper W, Konstantinides S, Geibel A. Prognostic significance of right ventricular afterload stress detected by echocardiography in patients with clinical suspected pulmonary embolism. Heart. 1997;77:346–9.CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Dellas C, Puls M, Lankeit M, Schäfer K, Cuny M, Berner M, Hasenfuss G, Konstantinides S. Elevated heart-type fatty acid-binding protein levels on admission predict an adverse outcome in normotensive patients with acute pulmonary embolism. J Am Coll Cardiol. 2010;55:2150–7.CrossRefPubMedGoogle Scholar
  35. 35.
    Lankeit M, Friesen D, Aschoff J, Dellas C, Hansefub G, Katus H, Konstantinides S, Giannitis E. Highly sensitive troponin T assay in normotensive patients with acute pulmonary embolism. Eur Heart J. 2010;31:1836–44.CrossRefPubMedGoogle Scholar
  36. 36.
    Borlaug BA, Paulus WJ. Heart failure with preserved ejection fraction: pathophysiology, diagnosis and treatment. Eur Heart J. 2011;32:670–9.CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Bogaard HJ, Natarajan R, Henderson SC, Long CS, Kraskauskas D, Smithson L, Ockaili R, McCord JM, Voelkel NF. Chronic pulmonary artery pressure elevation is insufficient to explain right heart failure. Circulation. 2009;120:1951–60.CrossRefPubMedGoogle Scholar
  38. 38.
    Silvain J, Collet JP, Nagaswami C, Beygui F, Edmondson KE, Bellemain-Appaix A, Cayla G, Pena A, Brugier D, Barthelemy O, Montalescot G, Weisel JW. Composition of coronary thrombus in acute myocardial infarction. J Am Coll Cardiol. 2011;57:1359–67.CrossRefPubMedPubMedCentralGoogle Scholar
  39. 39.
    Pollack CV, Schreiber D, Goldhaber SZ, Slattery D, Fanikos J, O’Neil BJ, Thompson JR, Hiestand B, Briese BA, Pendleton RC, Miller CD, Kline JA. Clinical characteristics, management, and outcomes of patients diagnosed with acute pulmonary embolism in the emergency department: initial report of EMPEROR (Multicenter Emergency Medicine Pulmonary Embolism in the Real World Registry). J Am Coll Cardiol. 2011;57:700–6.CrossRefPubMedGoogle Scholar
  40. 40.
    Laporte S, Mismetti P, Décousus H, Uresandi F, Otero R, Lobo JL, Monreal M, from the RIETE Investigators. Clinical predictors for fatal pulmonary embolism in 15 520 patients with venous thromboembolism findings from the Registro Informatizado de la Enfermedad Trombo Embolica venosa (RIETE) Registry. Circulation. 2008;117:1711–6.CrossRefPubMedGoogle Scholar
  41. 41.
    Steffel J, Braunwald E. Novel oral anticoagulants: focus on stroke prevention and treatment of venous thrombo-embolism. Eur Heart J. 2011;32:1968–76.CrossRefPubMedGoogle Scholar
  42. 42.
    Kaski JC, Arrebola-Moreno AL. Inflammation and thrombosis in atrial fibrillation. Rev Esp Cardiol. 2011;64:551–3.CrossRefPubMedGoogle Scholar
  43. 43.
    Gurbel PA, Tantry US. Antiplatelet and anticoagulants agents in heart failure. J Am Coll Cardiol FH. 2014;2:1–15.Google Scholar
  44. 44.
    Croce K, Libby P. Intertwining of thrombosis and inflammation in atherosclerosis. Curr Opin Hematol. 2007;14:55–61.CrossRefPubMedGoogle Scholar
  45. 45.
    Capodanno D, Angiolillo DJ. Antithrombotic therapy in the elderly. J Am Coll Cardiol. 2010;56:1683–92.CrossRefPubMedGoogle Scholar
  46. 46.
    Phrommintikul A, Kuanprasert S, Wongcharoen W, Kanjanavanit R, Chaiwarith R, Sukonthasarn A. Influenza vaccination reduces cardiovascular events in patients with acute coronary syndrome. Eur Heart J. 2011;32:1730–5.CrossRefPubMedGoogle Scholar
  47. 47.
    Pengo V, Lensing AWA, Prins MH, Marchiori A, Davidson BL, Tiozzo F, Albanese P, Biasiolo A, Pegoraro C, Iliceto S, Prandoni P, For the Thromboembolic Pulmonary Arterial Hypertension Group. Incidence of chronic thromboembolic pulmonary arterial hypertension after pulmonary embolism. N Engl J Med. 2004;350:2257–64.CrossRefPubMedGoogle Scholar
  48. 48.
    Becattini C, Agnelli G, Pesavento R, Siingardi M, Poggio R, Taliani MR, Ageno W. Incidence of chronic thromboembolic pulmonary arterial hypertension after a first episode of pulmonary embolism. Chest. 2006;130:172–5.CrossRefPubMedGoogle Scholar
  49. 49.
    Kline JA, Steuerwald MT, Marchichk M, Hernandez-Nino J, Rose GA. Prospective evaluation of right ventricular function and functional status six months after acute submassive pulmonary embolism. Frequency of persistent or subsequent elevation in estimated pulmonary artery pressure. Chest. 2009;136:1202–10.CrossRefPubMedPubMedCentralGoogle Scholar
  50. 50.
    Piazza G, Goldhaber SZ. Chronic thromboembolic pulmonary hypertension. N Engl J Med. 2011;364:351–60.CrossRefPubMedGoogle Scholar
  51. 51.
    A scientific statement from American Heart Association. Management of massive and submassive pulmonary embolism, ileofemoral deep venous thrombosis and chronic thromboembolic pulmonary hypertension. Circulation. 2011. doi: 10.1161/CIR.0b012e318214914f.
  52. 52.
    Jerjes-Sanchez C, Villarreal-Umaña S, Ramirez-Rivera A, Garcia-Sosa A, Canseco LM, Archondo T, Reyes E, Garza A, Arriaga R, Castillo F, Jasso O, Garcia H, Bermudez M, Hernández JM, Garcia J, Martinez P, Rangel F, Gutierrez J, Comparan A. Improving adjunctive treatment in pulmonary embolism and fibrinolytic therapy. The role of enoxaparin and weight-adjusted unfractionated heparin. J Thromb Thrombolysis. 2009;27:154–62.CrossRefPubMedGoogle Scholar
  53. 53.
    Meyer G, Vicaut E, Danays T, Agnelli G, Becattini C, Beyer-Westendorf J, Bluhmki E, Bouvaist H, Brenner B, Couturaud F, Dellas C, Empen K, Granca A, Galiè N, Geibel A, Goldhaber SZ, Jimenez D, Kozak M, Kupatt C, Kucher N, Lang IM, Lankeit M, Meneveau N, Pacouret G, Palazzini M, Petris A, Pruszczyk P, Rugolotto M, Salvi A, Schellong S, Sebbane M, Sobkowicz B, Stefanovic BS, Thiele H, Torbicki A, Verschuren F, Konstantinides SV, PEITHO Investigators. Fibrinolysis for patients with intermediate-risk pulmonary embolism. N Engl J Med. 2014;370:1402–11.CrossRefPubMedGoogle Scholar
  54. 54.
    Kline JA, Nordenholz KE, Courtney DM, Kabrhel C, Jones AE, Rondina MT, Diercks DB, Klinger JR, Hernandez J. Treatment of submassive pulmonary embolism with tenecteplase or placebo: cardiopulmonary outcomes at 3 months: multicenter double-blind, placebo-controlled randomized trial. J Thromb Haemost. 2014;12:459–68.CrossRefPubMedGoogle Scholar
  55. 55.
    Becattini C, Agnelli G, Salvi A, Grifoni S, Pancladi LG, Enea I, Blasemin F, Campanini M, Ghirarduzzi A, Casazza F, TIPES Study Group. Bolus tenecteplase for right ventricle dysfunction in hemodynamically stable patients with pulmonary embolism. Thromb Res. 2010;125:e82–6.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2015

Authors and Affiliations

  1. 1.Instituto de Cardiologia y Medicina Vascular, TEC SaludSan Pedro Garza GarciaMexico
  2. 2.Escuela de Medicina, Tecnológico de MonterreySan Pedro Garza GarciaMexico
  3. 3.Unidad de Investigacion Clinica en Medicina SCMonterreyMexico

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