Date sent: Sun, 31 Dec 1995 15:00:46 -0700 To: DEANDOBBERT@delphi.com From: Craig Feied Subject: emed-l Re: thrombolysis and PE Copies to: emed-l@itssrv1.ucsf.edu At 06:53 AM 12/31/95 -0500, Dean Dobbert wrote: >Your post on the CVA's also mentioned that you lysed all PE's. I'd like to >hear more about that. The feeling in the internists at my hospital is that >hemodynamically unstable PE's get lysed, all others just get heparin. What >do you think? Hi, Dean. My feeling is that this was an acceptable practice in the late 1970s, but is outdated today. The problem is that death is always from an embolism that hasn't happened yet, so severe hemodynamic compromise is a good predictor of immediate mortality, but a poor predictor of overall mortality. I do agree that ANY hemodynamic compromise is an absolute indication for thrombolysis or thrombectomy, because it 'proves' that the patient has exhausted his/her cardiopulmonary reserves and has little ability to withstand any further embolism. I review a number of legal cases each year, though, and every year I see more and more frequently the allegation that thrombolysis should have been given to a hemodynamically stable patient who went on to die (anywhere from minutes to months afterwards). The standard of care is changing, just as it has for acute MI. I have just finished writing the chapters of venous disease and on pulmonary embolism for the next edition of the Rosen text, and my desk is covered with 30 years of articles that are pretty darn convincing. I was personally convinced in 1989 when I wrote the PE chapter for the LAST edition, but at that time I was a 'bleeding-edger', as not more than a dozen institutions routinely lysed PE or DVT. Today, leading-edge institutions are randomizing their patients into different thrombolytic regimens, but very few would randomize to lytic treatment versus placebo. PE is the second most common cause of unexpected death, it is the single most common unrecognized cause of death found at autopsy, and it is probably the third most common immediate cause of death overall in hospitalized patients. Autopsy studies show that ten percent of patients who die in hospital after an acute MI actually die from PE, and the number is about the same for those who die in the hospital with 'pneumonia'. Just about every patient who dies from PE has multiple smaller prior PE's found at autopsy, and in fact half of the patients with a diagnosis of essential pulmonary hypertension actually have multiple chronic PE's instead. For those who might think I'm quoting a nonrepresentative subset of the literature, I can (and have) gone on for hundreds of pages with statements like these, which are referenced in my forthcoming Rosen chapters and also in my chapter in Gibler and Aufderheide's _Emergency_Cardiac_Care. Many of these references were cited in a four-article symposium I put together with several colleagues (also on this list) in January 1995 in Postgraduate Medicine. I've had a few requests to post my personal bibliography on the subject, but the last time I printed it out it ran to 400+ pages of 9-point type . I am working on a WAIS interface to my Reference Manager database, and if I ever get it working I'll install it on our http://ncemi.org site. In the meantime, I don't think you can force your internists to lyse all PE's this year, but they'll all be insisting on it in a few more years. You can make a much bigger impact on overall patient survival just by forcing your internists not to stop workups in patients with a nondiagnostic V/Q... Woops -- got a little carried away... didn't mean to make such a long post. Hope nobody responds... ==== from: ================================================== Craig Feied, MD FACEP cfeied@ncemi.org Director, National Center for 202.965.2001 voice Emergency Medicine Informatics 202.965.5316 fax http://ncemi.org =========================================================== =*=*=*=*=*=*=*=*=*= To remove yourself from emed-l send mail to majordomo@itssrv1.ucsf.edu with 'unsubscribe emed-l' in the body of the message.