Deciding on thrombolytic therapy in pulmonary embolism – is there room for lactate

Abstract

Introduction Diagnostic and therapeutic algorithms for pulmonary embolism (PE) have been frequently modified; however, determining clinical probability, which dictates further procedures, has remained the first step. The objective was to illustrate therapeutic dilemma in a patient with intermediate high risk for 30-day mortality.

Case outline The patient was a 56-years-old woman who was referred to our institution for suspected PE. According to the Wells score, the patient was deemed as low-probability for venous thromboembolism, and after further stratification she was placed in a group with intermediate high risk for 30-day mortality. PE was confirmed by computerised tomography pulmonary angiography and she initially received heparin. During the further clinical course, she developed hemodynamic instability, and she received thrombolytic therapy, with a positive outcome. The patient also had increased lactate at admission – marker of tissue hypoperfusion which is not a part of the routine laboratory work-up in PE patients.

Conclusion Current guidelines state that patients with intermediate high risk for 30-day mortality should be treated with heparin, and then continuously monitored in order to timely recognize potential hemodynamic instability and consequently apply thrombolytics. In the outlined case, thrombolytic therapy was applied only after the patient developed hemodynamic instability, although previously she had early signs of tissue hypoperfusion.

Keywords: pulmonary embolism; thrombolytic therapy; lactate