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Management issues in acute pulmonary embolism : Should heparin be started only after thrombolysis ?

Posted Oct 08 2010 9:48am

Acute pulmonary embolism is a vascular  emergency.Massive pulmonary embolism needs immediate thrombolysis or embolectomy. Success rate  of  thrombolysis  appears good . But , the symptom improvement  is slower .

Sterptokinase is the commonly used drug to dissolve the pulmonary thrombus  . (Except in USA , where they  prefer the much costlier TPA )

The sterptokinase  adminstered with the following protocol

  • 2.5 lakh Unit bolus over 30 minutes
  • Follow with 1lakh unit /per hour for the next 48 hours (Up to 72 h)

When to start Heparin infusion ?

For TPA ,  there is no confusion .Heparin must be started immediately after the completion of TPA infusion (100mg in 2 hours)

Cardiology community is divided for heparin protocol with  streptokinase. Because , streptokinase is administered over 48hours it is thought heparin is not required during  this period.But in reality , it  implies , we  deny a role for this  powerful anti thrombin  in the critical hours of ongoing  intra vascular clotting . Hence  logic demands  to start heparin  along with  streptokinase.

There is further concern that,  the dissolved thrombus generate pro coagulant  debri , that will negate the benefits of thrombolysis. Oral anticoagulants  are supposed to be started  as soon as the diagnosis  of pulmonary embolism is made. In that case , heparin will be required  much earlier as  warfarin has to be overlapped with heparin.

We would  argue for  , a careful simultaneous infusion of heparin (May be 500units/hour ) .Strict monitoring of APTT is warranted.

What does the clinical  trials say ?

There are few studies address this specific issue .I am still searching the data base. Once i get it i will post it. The readers  may also try to find an answer .


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