Fibrinolysis for intermediate-risk pulmonary embolism.
نویسنده
چکیده
To the Editor: In the Pulmonary Embolism Thrombolysis (PEITHO) study (April 10 issue),1 a bolus of unfractionated heparin was withheld from 303 patients because they had just received subcutaneous low-molecular-weight heparin or fondaparinux. Low-molecular-weight heparin in particular has a slow onset of action, taking 4 to 6 hours to reach full effect.2 This delay in the effect of treatment may have been unfavorable to patients not receiving tenecteplase, among whom the incidence of hemodynamic decompensation (often within the first day after randomization) was higher than that among patients receiving tenecteplase. Guidelines support the safety of low-molecularweight heparin in patients with pulmonary embolism. Caution is warranted, however, because the majority of relevant trials (10 of 12 trials in a key meta-analysis3) used low-molecular-weight heparin after an initial bolus of unfractionated heparin. Omitting this bolus may be unsafe, particularly in high-risk patients such as those involved in the PEITHO study. Previous guidelines have recommended a bolus of unfractionated heparin before the administration of lowmolecular-weight heparin.4 Later, for some reason, this recommendation disappeared. We would like to know outcome details of the subgroup of patients who did not receive an initial bolus of unfractionated heparin. If hemodynamic decompensation in the placebo group occurred primarily in this subgroup, the explanation may be a delayed onset of anticoagulant activity. Yvo Smulders, M.D.
منابع مشابه
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عنوان ژورنال:
- The New England journal of medicine
دوره 371 6 شماره
صفحات -
تاریخ انتشار 2014