Treatment of unstable pulmonary embolism in the elderly and those with comorbid conditions

Background: Although the in-hospital case fatality rate is lower in unstable patients with pulmonary embolism who receive thrombolytic therapy, less than one third receive it. The purpose of this investigation is to try to assess why most unstable patients fail to receive thrombolytic therapy and whether evidence might support a more aggressive approach.

Methods: Data were obtained from the Nationwide Inpatient Sample 1999-2008.

Results: Fewer unstable patients with pulmonary embolism accompanied by comorbid conditions received thrombolytic therapy than patients with no comorbid conditions, 11,670 of 60,100 (19.4%) vs 9710 of 12,130 (80.0%) (P<.0001). Fewer patients aged>60 years received thrombolytic therapy than patients aged≤60 years, both among those with comorbid conditions, 6330 of 37,320 (17.0%) vs 5340 of 22,780 (23.4%) (P<.0001), and among those without comorbid conditions, 3560 of 5060 (70.4%) vs 6150 of 7070 (87.0%) (P<.0001). However, even among elderly patients and those with comorbid conditions, the case fatality rate was lower with thrombolytic therapy. The odds ratio of in-hospital death (0.11-0.62) favored thrombolytic therapy irrespective of age or comorbidity.

Conclusion: Unstable patients with pulmonary embolism were less likely to receive thrombolytic therapy if they were elderly or had comorbid conditions, but those who received thrombolytic therapy had a lower in-hospital case fatality rate irrespective of age or comorbid conditions. The cautious approach of withholding thrombolytic therapy in those who might have major bleeding might not be the safest approach in terms of mortality and needs to be prospectively evaluated.