What's the best approach to pulmonary embolism? New study points to three letters: CDT

Catheter-directed thrombolysis (CDT) appears to be the best approach for patients with intermediate- or high-risk pulmonary embolism, according to a new study published recently in the Canadian Medical Association Journal. Compared with systemic thrombolysis, CDT had a lower risk of death and major bleeding, according to researchers at the Hebrew University of Jerusalem in Israel. Similar findings emerged when CDT was compared against anticoagulation: CDT was associated with a lower risk of death and potentially also with a lower risk of intracranial hemorrhage and major bleeding. “Although this study should be interpreted as hypothesis-generating, our findings suggest that, among patients eligible for CDT and where facilities exist, CDT should be the preferred treatment, given its effectiveness, and the higher toxicity of systemic thrombolysis,” wrote study co-author Dr. Bruria Hirsh Raccah, who is a faculty member at the university’s department of cardiology. Pulmonary embolism is the third leading cause of death from heart disease after myocardial infarction and stroke. According to Thrombosis Canada, this condition affects between one to two out of every 1,000 adults each year. The annual age-standardized mortality rate of pulmonary embolism among Canadians is about 2.6 deaths per 100,000 population, according to the study authors. Read: Study examines cardiovascular safety of Pfizer bivalent COVID-19 vaccine “An early diagnosis is essential as about one-third of deaths occur suddenly or within a few hours of the acute event,” they wrote. “About 40% of deaths are diagnosed post mortem, and only 7% of early deaths occur in patients who were properly diagnosed and treated.” The authors cited the three major therapeutic strategies for acute pulmonary embolism: hemodynamic and respiratory support, anticoagulation and reperfusion therapy with either systemic thrombolysis or catheter-directed therapy. Percutaneous CDT allows “slow and local infusion of thrombolytic material in low doses (about a quarter of the systemically administered dose), directly to the pulmonary arteries, with or without the use of mechanical or ultrasound fragmentation of the thrombus in situ,” explained the authors. There is, unfortunately, a lack of research in CDT’s efficacy and safety. “The evidence that currently supports the efficacy and safety of CDT in patients with acute (pulmonary embolism) is suboptimal,” the authors wrote. “Individual studies have produced mixed results, and study limitations make it difficult to draw definite conclusions. As a result of this uncertainty, treatment guidelines have varied considerably.” For this review, researchers conducted a network meta-analysis of 44 studies—including 19 randomized controlled trials—that involved an aggregate total of 20,006 patients. Although the study’s findings were “driven mainly by observational data, centres that specialize in CDT can consider it as first-line therapy among patients with intermediate-to high-risk (pulmonary embolism,” concluded the authors. Read: Which anticoagulant is the best to prevent recurrent VTE?

What's the best approach to pulmonary embolism? New study points to three letters: CDT

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