Treatment of Unstable Pulmonary Embolism in the Elderly and Those with Comorbid Conditions.

Department of Research, St Mary Mercy Hospital, Livonia, Mich. Electronic address: .
The American journal of medicine (Impact Factor: 5.3). 02/2013; DOI: 10.1016/j.amjmed.2012.12.007
Source: PubMed

ABSTRACT BACKGROUND: Although the in-hospital case fatality rate is lower in unstable patients with pulmonary embolism who receive thrombolytic therapy, less than one third receive it. The purpose of this investigation is to try to assess why most unstable patients fail to receive thrombolytic therapy and whether evidence might support a more aggressive approach. METHODS: Data were obtained from the Nationwide Inpatient Sample 1999-2008. RESULTS: Fewer unstable patients with pulmonary embolism accompanied by comorbid conditions received thrombolytic therapy than patients with no comorbid conditions, 11,670 of 60,100 (19.4%) vs 9710 of 12,130 (80.0%) (P<.0001). Fewer patients aged>60 years received thrombolytic therapy than patients aged≤60 years, both among those with comorbid conditions, 6330 of 37,320 (17.0%) vs 5340 of 22,780 (23.4%) (P<.0001), and among those without comorbid conditions, 3560 of 5060 (70.4%) vs 6150 of 7070 (87.0%) (P<.0001). However, even among elderly patients and those with comorbid conditions, the case fatality rate was lower with thrombolytic therapy. The odds ratio of in-hospital death (0.11-0.62) favored thrombolytic therapy irrespective of age or comorbidity. CONCLUSION: Unstable patients with pulmonary embolism were less likely to receive thrombolytic therapy if they were elderly or had comorbid conditions, but those who received thrombolytic therapy had a lower in-hospital case fatality rate irrespective of age or comorbid conditions. The cautious approach of withholding thrombolytic therapy in those who might have major bleeding might not be the safest approach in terms of mortality and needs to be prospectively evaluated.

  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: The current study describes the fibrinolytic treatment of a patient exhibiting an acute massive pulmonary thromboembolism, who was also receiving a bevacizumab-based combination regimen for metastatic colon cancer. The administration of bevacizumab has been associated with an increased risk of venous thromboembolic events and bleeding in cancer patients. However, there is insufficient data regarding the safety and activity of thrombolytic agents in cancer patients receiving bevacizumab-based therapy. In the present case, despite the increased risk of bleeding, low-dose and prolonged tissue plasminogen activator infusion was effectively and reliably applied to treat a massive pulmonary embolism, which resulted in hemodynamic instability in the patient.
    Oncology letters 12/2014; 8(6):2779-2781. DOI:10.3892/ol.2014.2568 · 0.99 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Elderly patients are a population not only at particularly high risk of venous thromboembolism including pulmonary embolism (PE), but also at high risk of adverse clinical outcomes and treatment-related complications. Major progresses have been achieved in the diagnosis and treatment of PE over the last two decades. Nevertheless, some of elderly patients' specificities still represent important challenges in the management of PE in this population, from its suspicion to its diagnosis and treatment, and are discussed in this review. Perspectives for the future are from a diagnostic point of view the potential implementation of age-adjusted d-dimer cut-offs that will allow ruling out PE in a greater proportion of elderly patients without the need for thoracic imaging. From a therapeutic point of view, acquisition of post-marketing clinical experience with the use of new oral anticoagulants is still necessary, and in the meantime, these drugs should be prescribed with great caution in thoroughly selected elderly patients.
    European Journal of Internal Medicine 04/2014; DOI:10.1016/j.ejim.2014.03.009 · 2.30 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: The relation of age to case fatality rate in patients undergoing pulmonary embolectomy has not been reported. In view of the importance of age in the selection of patients who may be candidates for pulmonary embolectomy, we explored the database of the Nationwide Inpatient Sample to determine the impact of age on case fatality rate. Patients with pulmonary embolism who underwent pulmonary embolectomy in short-stay hospitals throughout the United States, 1999- 2008, were identified from the Nationwide Inpatient Sample. In-hospital all-cause case fatality rate was assessed according to age. The proportion of patients who underwent pulmonary embolectomy decreased with age among both stable and unstable patients. Case fatality rate with pulmonary embolectomy in stable patients increased with age beginning at age 51-60 years. Among patients aged 51- 60 years, case fatality rate was 100 of 575 (17.4%). It increased to 60 of 130 (46.2%) among patients aged >80 years (P<0.0001). Case fatality rate did not correlate with age in unstable patients. Case fatality rate with pulmonary embolectomy in stable patients increases with age above 51-60 years and is high among the elderly. Case fatality rate of with pulmonary embolectomy in unstable patients does not appear to be age-related.
    The American journal of medicine 12/2013; 127(4). DOI:10.1016/j.amjmed.2013.11.011 · 5.30 Impact Factor