, Seda Tanyeri 2
, Berhan Keskin 3
, Hacer Ceren Tokgöz 2
, Dicle Sırma 2
, Çağdaş Buluş 2
, Şeyma Zeynep Atıcı 2
, Şeyma Nur Çiçek 2
, Furkan Baturalp Erdoğan 2
, Ahmet Sekban 2
, Mustafa Bulut 4
, Zübeyde Bayram 2
, Selahattin Akyol 2
, Aykun Hakgör 3
, Şeyhmus Külahçıoğlu 2
, Ali Karagöz 2
, Nihal Özdemir 2
, Cihangir Kaymaz 2
2Department of Cardiology, University of Health Sciences, Koşuyolu Heart Training and Research Hospital, İstanbul, Türkiye
3Department of Cardiology, Medipol University Faculty of Medicine, İstanbul, Türkiye
4Department of Cardiology, Ahi Evren Thoracic and Cardiovascular Surgery Training and Research Hospital, Trabzon, Türkiye
Abstract
Background: Intermediate-high-risk (IHR) pulmonary embolism (PE) is defined by right ventricular (RV) dysfunction and elevated cardiac troponin in the absence of hemodynamic instability. While full-dose thrombolysis may improve outcomes, it poses a high bleeding risk. This study assessed the safety and efficacy of a reduced-dose, slow-infusion thrombolytic regimen.
Methods: This single-center retrospective study included 124 patients with acute IHR PE who met at least one of the following criteria: systolic blood pressure ≤110 mm Hg, heart rate >100 bpm, SpO2 <90% on room air, respiratory rate >20/min, or lactate >2 mmol/L. Patients with contraindications to thrombolysis or symptom onset >14 days were excluded. Patients received 25 mg intravenous alteplase (t-PA) infused over 4-6 hours, along with standard anticoagulation according to the institutional protocol. Following the initial dose, a repeat infusion of 25 mg over 4-6 hours was administered if tachycardia, hypoxia, or signs of organ hypoperfusion persisted on re-evaluation.
Results: Syncope was the presenting symptom in 27.4%, and 49.2% had deep vein thrombosis. Median t-PA dose was 50 mg and median infusion duration was 6 hours. Significant improvements were observed in RV and RA size/function, thrombus burden, and clinical parameters (all P < .001). Qanadli score and RV/LV ratio decreased by 55% and 29%, respectively. Major and minor bleeding occurred in 4.8% and 3.2%. In-hospital mortality was 4.8%; 12-month survival was 89.5%. Chronic thromboembolic pulmonary hypertension developed in 3.2%.
Conclusion: Low-dose, slow-infusion t-PA therapy appears effective and well-tolerated, offering hemodynamic and clinical benefit with fewer bleeding complications in patients with IHR PE.