Thrombolysis for Pulmonary Embolism and Risk of All-Cause Mortality, Major Bleeding, and Intracranial Hemorrhage

Chatterjee. 2014 JAMA:311(23);2414-2421.

In patients with PE, does the addition of thrombolysis to anticoagulation, compared with anticoagulation alone, affect mortality and bleeding complications?
N = 2115 across 16 trials, Meta-analysis

Among patients with PE, including those who are haemodynamically stable, thrombolysis was associated with lower mortality and more major bleeding

Thrombolysis for PE is associated with a lower all cause mortality when compared to anticoagulation. This improvement is maintained in the subgroup of ‘intermediate risk’ PE with a NNT of 65. This is despite a significant increase in major bleeding in the thrombolysis group, with a NNH of 18. Of note, patients who were ≤65 years had no increase in major bleeding with thrombolysis.
With the MOPETT and TOPCOAT studies finding improved longterm outcomes with regards to pulmonary hypertension, and self assessment of overall health in the thrombolysis groups, this meta-analysis provides a convincing argument for the use of thrombolysis in submassive PE.
If I have a submassive PE, I want thrombolysis. (I am under 65 years). I would want half-standard dose as per the MOPETT trial. If my dad (he is over 65 years) had a sub-massive PE I would not recommend thrombolysis as the 12.9% chance of major bleeding means that the risks may outweigh the benefits.