Low Dose Prolonged Infusion of Tissue Type Plasminogen Activator Therapy in Massive Pulmonary Embolism

Study Overview
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Brief Summary
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The aim of the present study was to assess the effects of low-dose (25mg) prolonged administration (in 6 hours) of tissue type plasminogen activator (tPA) on in-hospital mortality and outcomes in patients with massive PE.

Detailed Description
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Pulmonary embolism (PE) is life threatening disease requiring early diagnosis and treatment. Thrombolytic therapy (TT) is required in patients with massive PE. PE has a high mortality but the in-hospital all-cause case mortality rates were lower in unstable patients who received TT than those who did not. However, it was reported that minority (nearly 30%) of unstable patients received thrombolytic therapy. The reason that majority of unstable patients failed to receive thrombolytic therapy is unclear. The higher rates of complications including the life threatening bleeding may be a reason of reluctance in the use of TT. The lungs are the only organ receiving the entire cardiac output. Therefore, they are the point of convergence for the entire molecules of the thrombolytic agent, independent from the route of administration. So that lower doses of the TT might be effective in PE, with the additional benefits of enhancing its safety profile. The percutaneous endovenous intervention for deep venous thrombosis has suggested an exquisitely favorable pulmonary response to low-dose thrombolysis. The aim of the present study was to assess the effects of low-dose (25mg) prolonged administration (in 6 hours) of tissue type plasminogen activator (tPA) on in-hospital mortality and outcomes in patients with massive PE. The primary end points consisted of in hospital all cause mortality, major complications, pulmonary hypertension and right ventricular dysfunction. Secondary points are all cause mortality, pulmonary hypertension and right ventricular dysfunction at 6 month.

Official Title
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Low Dose Prolonged Infusion of Tissue Type Plasminogen Activator Therapy in Massive Pulmonary Embolism: AYKAN Trial

Conditions
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Pulmonary Embolism

Intervention / Treatment
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* Drug: 25 mg Actilyse ( Boehringer Ingelheim, Germany) infusion in 6 hours


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Patients with massive PE aged 18 years or older with confirmed PE and able to give informed consent will be included in the study. PE is defined according to current guidelines as adult patients presenting with signs and symptoms suggestive of PE plus imaging documentation on computed tomography angiography. Massive PE was defined as acute PE with sustained hypotension (systolic blood pressure<90 mm Hg for at least 15 minutes or requiring inotropic support, not due to a cause other than PE, such as arrhythmia, hypovolemia, sepsis, or left ventricular [LV] dysfunction), pulselessness, or persistent profound bradycardia (heart rate<40 bpm with signs or symptoms of shock). Exclusion Criteria: Patients with prior intracranial hemorrhage, known structural intracranial cerebrovascular disease (eg, arteriovenous malformation), known malignant intracranial neoplasm, ischemic stroke within 3 months, suspected aortic dissection, active bleeding or bleeding diathesis, recent surgery encroaching on the spinal canal or brain, and recent significant closed-head or facial trauma with radiographic evidence of bony fracture or brain injury were excluded from the study.

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Intervention Model: Single Group Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Low dose prolonged infusion arm<br>Low dose prolonged infusion of tPA arm (25mg Actilyse in 6 hours) | Drug: 25 mg Actilyse ( Boehringer Ingelheim, Germany) infusion in 6 hours<br> <br> |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| All cause in hospital mortality | Death occured during hospitalization period. | participants will be followed for the duration of hospital stay, an expected average of 7 days | 
| Major complications | Major bleeding, intracranial bleeding, resuscitated cardiac arrest, thromboembolism and stroke are described as major complications. | participants will be followed for the duration of hospital stay, an expected average of 7 days. | 
| Development of pulmonary hypertension | Pulmonary artery systolic pressure >40mmHg measured by transthoracic echocardiography prior to discharge was described as pulmonary hypertension. | participants will be followed for the duration of hospital stay, an expected average of 7 days | 
| Right Ventricular dysfunction | Right ventricular dysfunction detected by transthoracic echocardiography: Decreased right ventricular diameter (at least 25% decrease of Right ventricle/Left ventricle diameter) Tricuspid annular plane systolic excursion>16mm) s'> 10.0 cm/s Tissue Doppler derived right ventricle myocardial performance index>0.55 | participants will be followed for the duration of hospital stay, an expected average of 7 days | 
| Restoration of hemodynamic status | Systolic blood pressure >100mmHG | 6 hours after the beginning of thrombolytic therapy | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Pulmonary hypertension | Pulmonary artery systolic pressure >40mmHg | 6 month | 
| Right ventricular dysfunction | Tricuspid annular plane systolic excursion >16mm s'> 10.0 cm/s Tissue Doppler derived right ventricle myocardial performance index>0.55 Right ventricle/Left ventricle diameter <1 | 6 months | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Massive Pulmonary embolism, thrombolytic therapy, high risk, elderly