Not even every fourth patient with pulmonary embolism and hemodynamic instability receives systemic lysis. There's still plenty of room for improvement.
Today, almost in vacation mode, we provide our readers with a simple blog post. The study we focus on comes from a renowned German institution, namely the Mainz University Medical Center (Universitätsmedizin Mainz), which issued not so positive news.
In the largest clinic in Rhineland-Palatinate, everything increased last year: the number of inpatients increased by 0.6% to 69,324 ("against the federal trend", as it is called), the number of outpatients treated by 1.2% to 282,317, the revenues from hospital operations by 4.1% to 457.6 million euros and the total turnover by 5.2% to 775.5 million euros.
So far so good. Unfortunately, the losses have also risen: by around 80% to 59.7 million euros. That's the worst news though. Although the state government does not expect a recovery in terms of the economic result, it does expect an improvement. And hopes for positive effects from the upcoming financial injection: In the double budget 2019/20, "70 million euros for the investment package and 10 million additional structural financings" are planned for the only university hospital in the Rhineland-Palatinate region. The red numbers will also translate into new reductions this year: 100 of the approximately 5,700 full-time jobs will be cut - in all areas except nursing care.
From the field of research, the Centre for Thrombosis and Haemostasis (CTH) of the Mainz University Medical Center, issued an interesting paper about the trends in the use of lysis therapy and the outcome in patients with acute pulmonary embolism in Germany (see source 1).
The clinical significance of pulmonary embolism is known to be enormous:
In recent decades, annual incidence rates of pulmonary embolism have increased, while mortality rates have fallen. The increase in new cases is likely to be due to both demographic and technological developments with improved imaging. The decrease in mortality, in turn, can be attributed to improved risk management on the one hand and to a higher number of patients with smaller, less dangerous embolisms on the other.
Nevertheless, pulmonary embolism remains the leading cause of preventable deaths in hospitalized patients, despite awareness campaigns on thrombosis prevention among experts and the general public (see source 1).
The current guidelines recommend systemic lysis therapy in hemodynamically unstable (high-risk) patients with pulmonary embolism. It should be considered in selected normotensive patients with impending decompensation. A survival advantage and thus support for this recommendation was found in a population-based study (see source 3) from the USA. At the same time, however, inadequate use of lysis therapy in accordance with the indication became apparent.
By German standards, both findings are now confirmed by the study from Mainz scientists, done in cooperation with the Berlin Charité University Hospital (see source 1). The data analysis of more than 885,000 patients with pulmonary embolism who were hospitalized in Germany between 2005 and 2015 resulted in the following findings:
Lysis therapy data indicated the following:
Compared to patients that underwent lysis therapy, non-lysed patients were more likely to have a higher age, to have surgery during inpatient stay and incidence of cancer.
The greatest benefit of drug reperfusion in hemodynamic instability came from patients with shock but still without circulatory arrest: Their hospital mortality rate without lysis was 49.9% vs. 28.6% with lysis (Odds Ratio or OR 0.42). There was also a survival benefit for CRP patients, but this was lower (OR 0.92). The rate of intracerebral bleeding increased from 0.7% to 1.5% under lysis in unstable pulmonary embolism patients.
Surgical reperfusion by embolectomy was used in a consistently small number of patients (0.2%) and also reduced mortality (OR 0.55).
A reduction of hospital mortality by more than 50%, regardless of age, sex and concomitant diseases, is impressive. In pulmonary embolism patients with circulatory instability, systemic lysis should be used as early as possible, provided there are no absolute contraindications. Limitation of the study: no data on concomitant medication, course of circulatory instability and causes of death.
Sources
1. Keller K et al. Trends in thrombolytic treatment and outcomes of acute pulmonary embolism in Germany. Eur Heart J. 2019. pii:ehz236. doi:10.1093/eurheartj/ehz236
2. Wilkens H, hero M. pulmonary artery embolism: status 2018. Dtsch Arztebl 2018;115(24):[8]. doi:10.3238/PersPneumo.2018.06.15.002
3. stone PD, Matta F. thrombolytic therapy in unstable patients with acute pulmonary embolism: saves lives but underused. On J Med 2012;125:465-70