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Tabla 1.
Criterios de disfunción del VD empleados en la literatura en EP aguda
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heparina sola. Como la falla cardíaca derecha es la causa usual de muerte debida a EP,
su mejoría por los agentes fibrinolíticos debería reflejarse en cambios en la mortalidad.
Desafortunadamente, la literatura contiene muchos ejemplos de mejoría de un marcador
pronóstico por un tratamiento dado que no se traslada en beneficio clínicoxvii. En el
estudio de Hamel y colsxviii, los pacientes tratados con fibrinolíticos presentaron mejor
evolución en la gamagrafia pulmonar a la semana del tratamiento, que los que
recibieron sólo heparina, pero la frecuencia de mortalidad fue mayor en el grupo tratado
con fibrinolìticos. Debido al sesgo inherente al diseño de este estudio no se delinearon
conclusiones definitivas.
Tabla 2
Regímenes fibrinolíticos empleados en el tratamiento del tromboembolismo venoso
Droga Régimen
Estreptoquinasa - 250.000 U en 30 min seguido por 100.000 U/hs en 24 hs.
- 250.000 U en 30 min seguido por 100.000 U/hs en 12 hs.
- 1.500.000 U en 1-2 hs.
Uroquinasa - 4.400 U/kg. en 10 min seguido de 4.400 U/kg/hs en 24 hs.
- 4.400 U/kg. en 10 min seguido de 4.400 U/kg/hs en 12 hs.
- 1.000.000 U en 10 min seguido de 2.000.000 U en 110 min.
Rt-PA - 100 mg en 2 hs.
Retaplase - 2 inyecciones de 10 U c/u, separadas una de otra por 30 min.
Tenecteplase - inyección en bolo en 5 segundos
fue 15.6% en pacientes con agrandamiento del VD, vs 7.7% en aquellos sin
agrandamiento del VD.
Bibliografía
i
Kasper W,. Konstantinides S, Geibel A, et al. Management strategies and determinats of outcome acute
major pulmonary embolism: results of a multicenter registry. J Am Coll Cardiol 1997; 30; 1165-1171.
ii
Goldhaber SZ, Elliot CG. Acute pulmonary embolism: Risk stratification, treatment, and prevention.
Circulation 2003; 108: 2834-2838.
iii
Buller HR, Agnelli G, Hull RD, Hyers TM, Prins MH, Raskob GE. Antithrombotic therapy for venous
thromboembolic disease: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy.
Chest 2004; 126: 401S-428S.
iv
Task Force on Pulmonary Embolism. European Society of Cardiology. Guidelines on diagnosis
andmanagement of acute pulmonary embolism. Eur Herat J 2000; 21: 1301-1336.
v
Thabut G, Logcart D. Thrombolysis for Pulmonary Embolism in patients with Right Ventricular
Dysfunction. Arch Intern Med 2005; 165: 2200-2203.
vi
Arcasoy SM, Vachani A. Local and systemic thrombolytic therapy for acute venous thromboembolism.
Clin Chest Med 2003; 24: 73-91.
vii
Goldhaber SZ. Thrombolytic therapy for patients with pulmonary embolism who are hemodinamically
stable but have right ventricular dysfunction. Arch Intern Med 2005; 165: 2197-2199.
viii
Kucher N, Goldhaber SZ. Cardiac biomarkers for risk stratification of patients with acute pulmonary
embolism. Circulation 2003; 108; 2191-2194.
ix
Goldhaber SZ. Echocardiography in the management of pulmonary embolism. Ann Intern Med 2002;
136: 691-700.
x
Schoepf UJ, Kucher N, Kipfmueller D, Quiroz R, Castello P, Goldhaber SZ. Right ventricular
enlargement on chest computed tomography: a predictor of early death in acute pulmonary embolism.
Circulation 2004; 110: 3276-3280.
Página 7
xi
Kucher N, Walpoth N, Wustmann K, Noveanu M, Gertsch M, QR in V1 an ECG sign associated with
right ventricular strain and adverse clinical outcome in pulmonary embolism. Eur Heart J 2003; 24: 1113-
1119.
xii
ten Wolde M, Sohne M, Quak E, Mac Gillavry MR, Buller HR. Prognostic value of
echocardiographically assessed right ventricular dysfunction in patients with pulmonary embolism. Arch
Intern Med 2004; 164: 1685-1689.
xiii
Vieillard-Baron A, Prins S, Chergui K, Dubourg O, Jardin F. Echo Doppler demostration of acute cor
pulmonale at the bedside in the medical intensive care unit. Am J Respir Crit Care Med 2002; 166: 1310-
1319.
xiv
Yasuda T, Okada RD, Leinbach RC, et al. Serial evaluation of right ventricular dysfunction associated
with acute inferior myocardial infarction. Am Herat J 1990; 119: 816-822.
xv
Goldhaber SZ, Elliot CG. Acute pulmonary embolism. Epidemiology, pathophysiology, and diagnosis.
Circulation 2003; 108: 2726-2729.
xvi
Goldhaber SZ, Haire WD, Feldstein MI, et al. Alteplase vs heparin in acute pulmonary embolism:
randomised trial assessing right ventricular function and pulmonary perfusion. Lancet 1993;347: 507-511.
xvii
Fleming TR, DeMets DL. Surrogate end points in clinical trials: are we being misled?. Ann Intern
Med 1996; 125: 605-613.
xviii
Hamel E, Pacouret G, Vincentell D, et al. Thrombolysis or heparin therapy in massive pulmonary
embolism with right ventricular dilatation: results from a 128 patient monocenter regisry. Chest 2001;
120: 120-125.
xix
Jerjes-Sanchez C, Ramírez-Rivera A, de Lourdes Garcia M, Arriaga-Nava R, Valencia S, Rosado-
Buzzo A, Pierzo JA, Rosas E. Streptokinase and Heparin versus Heparin Alone in Massive Pulmonary
Embolism: A Randomized Controlled Trial. J Thromb Thrombolysis. 1995; 2(3): 227-229.
xx
Grifoni S, Olivotto I, Cechini P. Short term clinical outcome of patients with acute pulmonary
embolism, normal blood presure, and echocardiography right ventricular dysfunction. Circulation 2000;
101: 2817-2822
xxi
Ribeiro A, Lindmarker P, Juhlin-Dannfelt A, Johnsson H, Jorfeldt L. Echocardiography doppler in
pulmonary embolism: right ventricular dysfunction as a predictor of mortality rate. Am Heart J 1997;
134: 479-487.
xxii
Kucher N, Rossi E, De Rosa M, Goldhaber SZ. Prognostic role of echocardiography among patients
with acute pulmonary embolism and preserved systemic arterial pressure. Arch Inter Med 2005; 165:
1777-1781.
xxiii
Goldhaber SZ,Visani L, De Rosa M. Acute pulmonary embolism: clinical outcomes in the
International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet 1999; 353: 1386-1389.
xxiv
Konstantinides S, Geibel A, Heusel G, Heinrich F, Kasper W. Management Strategies ad Prognosis of
Pulmonary Embolismo-3 Trial Investigators. Heparin plus alteplase compared heparin alone in patients
with submassive pulmonary embolism (MAP-PET-3). N Engl J Med 2002; 347: 1143-1150.
xxv
Aklog L, Williams C, Byrne J, Goldhaber SZ. Acute pulmonary embolectomy. A contemporary
approach. Circulation 2002; 105: 1416-1419.
xxvi
Kucher N,Windecker S, Banz Y, et al. Percutaneous catheter thrombectomy device for acute
pulmonary embolism: in vitro and in vivo testing . Radiology doi: 101148 / radiol 2363041287. Accessed
August 15, 2005.
xxvii
Tapson VF. The evolution and impact of the American College of Chest Physicians Consensus
statement on antithrombotic therapy. Clin Chest Med 2003; 24: 139-151.
xxviii
Wan S, Quintan DJ, Agnelli G, Eikelbom JW. Thrombolysis compared with heparin for the initial
treatment of pulmonary embolism: a meta-analysis of the randomized controlled trials. Circulation 2004;
110: 744-749.
xxix
Altman R, Rouvier J, Scazziota A, Abreu M. Tratamiento de la trombosis venosa profunda y de la
embolia de pulmón. en Evidencias en Cardiología IV. Editores Doval HC, Tajer CD. Cap.33; pag.775-
789.
xxx
Goldhaber SZ. Thrombolysis in pulmonary embolism: a large-scale clinical trials is verdue.
Circulation 2001; 104: 2876-2878.
xxxi
Thabut G, Thabut D, Myers RP, et al. Thrombolytic therapy of pulmonary embolism: a meta-analysis.
J Am Coll Cardiol 2002; 40: 1660-1667.
xxxii
Agnelli G, Becattini C, Kirschstein T. Thrombolysis vs heparin in the treatment of pulmonary
embolism: a clinical outcome based meta-analysis. Arch Intern Med 2002; 162: 2537-2541.
xxxiii
Dalen JE, Alpert JS, Hirsch J. Thrombolytic therapy for pulmonary embolism: is it effective? is it
safe? when is it indicated?. Arch Intern Med 1997; 157: 2550-2556.
Página 8
xxxiv
Levine MN. Thrombolytic therapy for venous thromboembolism: complications and
contraindications. Clin Chest Med 1995; 16: 321-328.
xxxv
Goldhaber SZ. Pulmonary embolism. Lancet 2004; 363: 1295-1305.