Victor F. Tapson, MD

More than a decade ago, we surveyed a group of practicing pulmonologists to determine their attitudes regarding the use of thrombolytic therapy in various settings of acute venous thromboembolism (VTE).1 Since that time, the literature regarding the treatment of acute VTE has grown dramatically.214 However, despite the available evidence, there remains considerable controversy regarding the appropriate setting for thrombolysis in acute pulmonary embolism (PE) or deep‐vein thrombosis (DVT). We therefore sought to better describe the current patterns of thrombolytic use among practicing pulmonologists and to determine if these patterns have changed over the last decade.

Methods

Five‐hundred and ten physicians in the southeastern US were selected from the American Thoracic Society (ATS) membership roster and were e‐mailed a link to an online questionnaire. The roster was searched for physicians who described their subspecialty as pulmonary disease or pulmonary and critical care.

Participants were asked background information and questions regarding hypothetical clinical scenarios. All participants were offered a $50 stipend, and to further improve the response rate, 2 reminder e‐mail messages were sent 30 days and 45 days after the initial request.

Baseline findings of the survey were summarized using descriptive statistics. Differences among participants and their responses were determined by Fisher's exact test. Analyses were performed using SAS E‐Guide Version 3.0 for Windows (SAS Institute, Cary, NC) with 2‐sided P values at the standard 0.05 level used to determine statistical significance.

Results

Use of Thrombolytic Therapy When Contraindications Exist

The vast majority of respondents reported that they would consider giving thrombolytic therapy to a patient with massive PE and hypotension requiring vasopressor therapy despite having a traditional contraindication (relative or absolute) to thrombolysis (Table 3). Most respondents would consider giving thrombolytic therapy to postoperative orthopedic, abdominal, or thoracic surgery patients if they were more than 2 weeks postoperation, and very few would give thrombolytic therapy to patients who were less than 2 days postoperation. Many respondents would also consider giving thrombolytic therapy to a patient with a massive PE and with a history of major gastrointestinal (GI) bleeding (requiring blood transfusion) if the bleed was more than 4 weeks prior to the embolism (Figure 1).

Figure 1

Table 3.Strong Consideration of Thrombolytic Therapy for Hemodynamically Significant PE in the Context of Absolute or Relative Contraindications

Condition	Number of Physicians (%)
Abbreviations: CPR, cardiopulmonary resuscitation; ICH, intracranial hemorrhage.
Age >75 years	58 (72)
Guaiac + stool	54 (67)
CPR in past 10 days	39 (48)
History of ischemic stroke	37 (46)
Recent venipuncture of a noncompressible vessel	33 (41)
History of ICH	6 (7)
Brain tumor	6 (7)
Would never use thrombolytics in these scenarios	7 (9)

Discussion

Given the paucity of data from randomized controlled trials, there remains considerable controversy regarding the indications for thrombolytic therapy. It may be difficult to define those patients in whom the benefit of a rapid reduction in clot burden outweighs the increased hemorrhagic risk. The case for thrombolysis is the strongest in patients with massive PE complicated by hypotension, in whom the mortality rate may be 30%.15 Our survey confirms that the vast majority of practicing pulmonologists would strongly consider systemic thrombolysis in this clinical setting, which is in accordance with current guidelines and with our previous survey results.1, 5, 10, 12

No clinical trial has specifically evaluated thrombolytic therapy in patients with large PE and hypoxemia but without hypotension, and it is interesting that so many physicians would consider thrombolytic therapy in this scenario. As right heart failure is the cause of death in PE, the absence of significant hypotension would imply less cardiovascular risk and thrombolytic use would seemingly be less justifiable from a physiologic point of view. It may be that further study and education is warranted in this area.

Many patients who present with acute, life‐threatening PE have contraindications or relative contraindications to systemic thrombolysis. Our study suggests that most practicing pulmonologists would consider giving thrombolytic therapy in some of these situations, such as if the patient was more than 2 weeks postoperative from major thoracic or abdominal surgery (or even a few days following orthopedic surgery), or in the setting of advanced age or guaiac positive stools. Physicians were appropriately very reluctant to use thrombolytic therapy in the setting of a brain tumor or prior intracranial hemorrhage. These scenarios emphasize the vagaries of the current guidelines and real‐world complexities of considering thrombolytic therapy in clinical practice, in which the risks and benefits must be weighed on a case‐by‐case basis.

One major difference between our current and past findings is the general experience with thrombolytic therapy in acute PE. In our first study, only 54% of physicians queried had employed systemic thrombolysis for acute PE. Our current findings were that 84% of physicians had used thrombolysis for acute PE within the last 2 years, perhaps suggesting a greater comfort with this therapy.

Response bias is a major limitation of our study. We sought to keep questions short and clear, and offered a small stipend to improve the return rate. Despite these measures, only 81 of 510 questionnaires were completed. We selected our list of participants from the ATS roster and by geographic location. As suggested by our findings, the results may have been different had we focused solely on VTE experts or those treating large numbers of VTE patients. One strength of this study is that our sample had approximately even numbers of academic and private practice physicians, and that we could compare current results with our prior findings.

In conclusion, practicing pulmonologists generally agreed that in the absence of contraindications, thrombolytic therapy should be considered in patients with massive PE and hypotension, which is in accordance with current guidelines. Furthermore, a majority would still consider thrombolytic therapy in this scenario even if certain contraindications were present. Although there is less agreement in other scenarios, a majority of physicians would consider using thrombolytics in patients with PE and severe hypoxemia or right ventricular (RV) dysfunction. Despite the evolving data and guidelines, our findings are similar to prior survey results, with the notable exception that more physicians reported thrombolytic therapy use in acute PE in the current study. This emphasizes the need for further physician education and future randomized clinical trials to delineate and unify therapeutic strategies in cases of VTE.

More than a decade ago, we surveyed a group of practicing pulmonologists to determine their attitudes regarding the use of thrombolytic therapy in various settings of acute venous thromboembolism (VTE).1 Since that time, the literature regarding the treatment of acute VTE has grown dramatically.214 However, despite the available evidence, there remains considerable controversy regarding the appropriate setting for thrombolysis in acute pulmonary embolism (PE) or deep‐vein thrombosis (DVT). We therefore sought to better describe the current patterns of thrombolytic use among practicing pulmonologists and to determine if these patterns have changed over the last decade.

Methods

Five‐hundred and ten physicians in the southeastern US were selected from the American Thoracic Society (ATS) membership roster and were e‐mailed a link to an online questionnaire. The roster was searched for physicians who described their subspecialty as pulmonary disease or pulmonary and critical care.

Participants were asked background information and questions regarding hypothetical clinical scenarios. All participants were offered a $50 stipend, and to further improve the response rate, 2 reminder e‐mail messages were sent 30 days and 45 days after the initial request.

Baseline findings of the survey were summarized using descriptive statistics. Differences among participants and their responses were determined by Fisher's exact test. Analyses were performed using SAS E‐Guide Version 3.0 for Windows (SAS Institute, Cary, NC) with 2‐sided P values at the standard 0.05 level used to determine statistical significance.

Results

Use of Thrombolytic Therapy When Contraindications Exist

The vast majority of respondents reported that they would consider giving thrombolytic therapy to a patient with massive PE and hypotension requiring vasopressor therapy despite having a traditional contraindication (relative or absolute) to thrombolysis (Table 3). Most respondents would consider giving thrombolytic therapy to postoperative orthopedic, abdominal, or thoracic surgery patients if they were more than 2 weeks postoperation, and very few would give thrombolytic therapy to patients who were less than 2 days postoperation. Many respondents would also consider giving thrombolytic therapy to a patient with a massive PE and with a history of major gastrointestinal (GI) bleeding (requiring blood transfusion) if the bleed was more than 4 weeks prior to the embolism (Figure 1).

Figure 1

Table 3.Strong Consideration of Thrombolytic Therapy for Hemodynamically Significant PE in the Context of Absolute or Relative Contraindications

Condition	Number of Physicians (%)
Abbreviations: CPR, cardiopulmonary resuscitation; ICH, intracranial hemorrhage.
Age >75 years	58 (72)
Guaiac + stool	54 (67)
CPR in past 10 days	39 (48)
History of ischemic stroke	37 (46)
Recent venipuncture of a noncompressible vessel	33 (41)
History of ICH	6 (7)
Brain tumor	6 (7)
Would never use thrombolytics in these scenarios	7 (9)

Discussion

Given the paucity of data from randomized controlled trials, there remains considerable controversy regarding the indications for thrombolytic therapy. It may be difficult to define those patients in whom the benefit of a rapid reduction in clot burden outweighs the increased hemorrhagic risk. The case for thrombolysis is the strongest in patients with massive PE complicated by hypotension, in whom the mortality rate may be 30%.15 Our survey confirms that the vast majority of practicing pulmonologists would strongly consider systemic thrombolysis in this clinical setting, which is in accordance with current guidelines and with our previous survey results.1, 5, 10, 12

No clinical trial has specifically evaluated thrombolytic therapy in patients with large PE and hypoxemia but without hypotension, and it is interesting that so many physicians would consider thrombolytic therapy in this scenario. As right heart failure is the cause of death in PE, the absence of significant hypotension would imply less cardiovascular risk and thrombolytic use would seemingly be less justifiable from a physiologic point of view. It may be that further study and education is warranted in this area.

Many patients who present with acute, life‐threatening PE have contraindications or relative contraindications to systemic thrombolysis. Our study suggests that most practicing pulmonologists would consider giving thrombolytic therapy in some of these situations, such as if the patient was more than 2 weeks postoperative from major thoracic or abdominal surgery (or even a few days following orthopedic surgery), or in the setting of advanced age or guaiac positive stools. Physicians were appropriately very reluctant to use thrombolytic therapy in the setting of a brain tumor or prior intracranial hemorrhage. These scenarios emphasize the vagaries of the current guidelines and real‐world complexities of considering thrombolytic therapy in clinical practice, in which the risks and benefits must be weighed on a case‐by‐case basis.

One major difference between our current and past findings is the general experience with thrombolytic therapy in acute PE. In our first study, only 54% of physicians queried had employed systemic thrombolysis for acute PE. Our current findings were that 84% of physicians had used thrombolysis for acute PE within the last 2 years, perhaps suggesting a greater comfort with this therapy.

Response bias is a major limitation of our study. We sought to keep questions short and clear, and offered a small stipend to improve the return rate. Despite these measures, only 81 of 510 questionnaires were completed. We selected our list of participants from the ATS roster and by geographic location. As suggested by our findings, the results may have been different had we focused solely on VTE experts or those treating large numbers of VTE patients. One strength of this study is that our sample had approximately even numbers of academic and private practice physicians, and that we could compare current results with our prior findings.

In conclusion, practicing pulmonologists generally agreed that in the absence of contraindications, thrombolytic therapy should be considered in patients with massive PE and hypotension, which is in accordance with current guidelines. Furthermore, a majority would still consider thrombolytic therapy in this scenario even if certain contraindications were present. Although there is less agreement in other scenarios, a majority of physicians would consider using thrombolytics in patients with PE and severe hypoxemia or right ventricular (RV) dysfunction. Despite the evolving data and guidelines, our findings are similar to prior survey results, with the notable exception that more physicians reported thrombolytic therapy use in acute PE in the current study. This emphasizes the need for further physician education and future randomized clinical trials to delineate and unify therapeutic strategies in cases of VTE.

More than a decade ago, we surveyed a group of practicing pulmonologists to determine their attitudes regarding the use of thrombolytic therapy in various settings of acute venous thromboembolism (VTE).1 Since that time, the literature regarding the treatment of acute VTE has grown dramatically.214 However, despite the available evidence, there remains considerable controversy regarding the appropriate setting for thrombolysis in acute pulmonary embolism (PE) or deep‐vein thrombosis (DVT). We therefore sought to better describe the current patterns of thrombolytic use among practicing pulmonologists and to determine if these patterns have changed over the last decade.

Methods

Five‐hundred and ten physicians in the southeastern US were selected from the American Thoracic Society (ATS) membership roster and were e‐mailed a link to an online questionnaire. The roster was searched for physicians who described their subspecialty as pulmonary disease or pulmonary and critical care.

Participants were asked background information and questions regarding hypothetical clinical scenarios. All participants were offered a $50 stipend, and to further improve the response rate, 2 reminder e‐mail messages were sent 30 days and 45 days after the initial request.

Baseline findings of the survey were summarized using descriptive statistics. Differences among participants and their responses were determined by Fisher's exact test. Analyses were performed using SAS E‐Guide Version 3.0 for Windows (SAS Institute, Cary, NC) with 2‐sided P values at the standard 0.05 level used to determine statistical significance.

Results

Use of Thrombolytic Therapy When Contraindications Exist

The vast majority of respondents reported that they would consider giving thrombolytic therapy to a patient with massive PE and hypotension requiring vasopressor therapy despite having a traditional contraindication (relative or absolute) to thrombolysis (Table 3). Most respondents would consider giving thrombolytic therapy to postoperative orthopedic, abdominal, or thoracic surgery patients if they were more than 2 weeks postoperation, and very few would give thrombolytic therapy to patients who were less than 2 days postoperation. Many respondents would also consider giving thrombolytic therapy to a patient with a massive PE and with a history of major gastrointestinal (GI) bleeding (requiring blood transfusion) if the bleed was more than 4 weeks prior to the embolism (Figure 1).

Figure 1

Table 3.Strong Consideration of Thrombolytic Therapy for Hemodynamically Significant PE in the Context of Absolute or Relative Contraindications

Condition	Number of Physicians (%)
Abbreviations: CPR, cardiopulmonary resuscitation; ICH, intracranial hemorrhage.
Age >75 years	58 (72)
Guaiac + stool	54 (67)
CPR in past 10 days	39 (48)
History of ischemic stroke	37 (46)
Recent venipuncture of a noncompressible vessel	33 (41)
History of ICH	6 (7)
Brain tumor	6 (7)
Would never use thrombolytics in these scenarios	7 (9)

Discussion

Given the paucity of data from randomized controlled trials, there remains considerable controversy regarding the indications for thrombolytic therapy. It may be difficult to define those patients in whom the benefit of a rapid reduction in clot burden outweighs the increased hemorrhagic risk. The case for thrombolysis is the strongest in patients with massive PE complicated by hypotension, in whom the mortality rate may be 30%.15 Our survey confirms that the vast majority of practicing pulmonologists would strongly consider systemic thrombolysis in this clinical setting, which is in accordance with current guidelines and with our previous survey results.1, 5, 10, 12

No clinical trial has specifically evaluated thrombolytic therapy in patients with large PE and hypoxemia but without hypotension, and it is interesting that so many physicians would consider thrombolytic therapy in this scenario. As right heart failure is the cause of death in PE, the absence of significant hypotension would imply less cardiovascular risk and thrombolytic use would seemingly be less justifiable from a physiologic point of view. It may be that further study and education is warranted in this area.

Many patients who present with acute, life‐threatening PE have contraindications or relative contraindications to systemic thrombolysis. Our study suggests that most practicing pulmonologists would consider giving thrombolytic therapy in some of these situations, such as if the patient was more than 2 weeks postoperative from major thoracic or abdominal surgery (or even a few days following orthopedic surgery), or in the setting of advanced age or guaiac positive stools. Physicians were appropriately very reluctant to use thrombolytic therapy in the setting of a brain tumor or prior intracranial hemorrhage. These scenarios emphasize the vagaries of the current guidelines and real‐world complexities of considering thrombolytic therapy in clinical practice, in which the risks and benefits must be weighed on a case‐by‐case basis.

One major difference between our current and past findings is the general experience with thrombolytic therapy in acute PE. In our first study, only 54% of physicians queried had employed systemic thrombolysis for acute PE. Our current findings were that 84% of physicians had used thrombolysis for acute PE within the last 2 years, perhaps suggesting a greater comfort with this therapy.

Response bias is a major limitation of our study. We sought to keep questions short and clear, and offered a small stipend to improve the return rate. Despite these measures, only 81 of 510 questionnaires were completed. We selected our list of participants from the ATS roster and by geographic location. As suggested by our findings, the results may have been different had we focused solely on VTE experts or those treating large numbers of VTE patients. One strength of this study is that our sample had approximately even numbers of academic and private practice physicians, and that we could compare current results with our prior findings.

In conclusion, practicing pulmonologists generally agreed that in the absence of contraindications, thrombolytic therapy should be considered in patients with massive PE and hypotension, which is in accordance with current guidelines. Furthermore, a majority would still consider thrombolytic therapy in this scenario even if certain contraindications were present. Although there is less agreement in other scenarios, a majority of physicians would consider using thrombolytics in patients with PE and severe hypoxemia or right ventricular (RV) dysfunction. Despite the evolving data and guidelines, our findings are similar to prior survey results, with the notable exception that more physicians reported thrombolytic therapy use in acute PE in the current study. This emphasizes the need for further physician education and future randomized clinical trials to delineate and unify therapeutic strategies in cases of VTE.