This week’s 52 in 52 Review


    This week’s 52 in 52 Review

    Title: “The 52 in 52 Review: Heparin plus TPA compared to Heparin alone for Submassive PE”

    Article Citation: Konstantinides S, Geibel A, Heusel G, Heinrich F, Kasper W; Management Strategies and Prognosis of Pulmonary Embolism-3 Trial Investigators. Heparin plus alteplase compared with heparin alone in patients with submassive pulmonary embolism. N Engl J Med. 2002 Oct 10;347(15):1143-50. PMID: 12374874

    What we already know about the topic: Alteplase or thrombolysis is indicated therapy in  hemodynamically unstable patients with massive pulmonary embolism (PE). Treatment for submassive hemodynamically stable PE remains controversial. Few studies have demonstrated a risk-benefit ratio for thrombolysis for submassive stable PE.

    Why this study is important: In this study, the authors compare treatment of Heparin plus placebo to Heparin plus thrombolysis in patients with submassive PE to demonstrate  risk vs benefit. This can potentially change practice management of stable submassive PE patients.

    Brief overview of the study: This study is a prospective randomized double blinded placebo-controlled trial. 256 patients were randomized to receive either Heparin and Alteplase or Heparin and placebo. Randomized groups were similar in patient demographic and clinical parameters at baseline. Primary end-point was in hospital death or clinical deterioration which required an escalation in treatment. There was a statistically significant increased incidence of the primary endpoint in the Heparin/Placebo group vs the Heparin/Alteplase group. (24% vs 11%, p = 0.006). Escalation of treatment was also significantly higher in the placebo group as well (24% vs 10%, p = 0.004). Requirement for secondary thrombolysis was again increased in the placebo group (23% vs 9%, p = 0.001). All secondary endpoints; recurrent PE, major bleeding, fatal bleeding, hemorrhagic stroke, were similar in each group without statistical difference.

    Limitations: My primary issues with this study are: (1) A very low (N), 286 patients were randomized to either group which is a small sample size. (2) In hospital mortality rates were uncharacteristically low in this study when compared to the national average for PE by the PE registry (8%), which may have been due to uncovered confounders.  

    Take home points: I believe further large scale multicentered studies are needed to determine the benefit of Alteplase and Heparin for hemodynamically stable sub massive PE patients.


    • Welcome! This is the website for the Mount Sinai Emergency Ultrasound Division. It serves as an information resource for residents, fellows, medical students and others seeking information about point-of-care ultrasound. There is a lot ofRead more

    • E-point Septal Separation in the Patient with Congestive Heart Failure

      Perhaps never explained so clearly, Cisewki and Alerhand’s article on EPSS is a wonderful read. Bottom line to remember: EPSS > 7 mm was 87% sensitive and 75% specific at identifying reduced EF (<50%).  This isRead more

    • Lidocaine for cough?

      Whether it’s asthma, a U.R.I., or post nasal drip as the cause, cough is a common enough complaint encountered by emergency physicians everywhere. Of course you must always rule out the dangerous causes of coughRead more

    • Measles redux!

      A quick search of for the keyword measles brings up a solitary post from 2015, and it’s not actually about measles. With all the attention that measles has been getting in the news recently,Read more

    • The Apple Watch Heart Study

      Disclosure: I’m a huge Apple Fan. Unless you’ve been living under a rock, you’ve heard about the Apple watch, many of you reading this are wearing one right now. On April 24th, 2015 it joinedRead more

    • Peritonsillar Abscess I&D…Can you ditch the endocavitary probe?

      Today’s post is inspired by real-life events and comes with a video (consent given by the patient and providers). The case: 29M presents with dysphonia, odynophagia, and drooling. He is hypertensive, with a low-grade fever,Read more

    • Look into my seeing EYE ball

      THE EYE EXAM Keep it basic… APD Intra-ocular Pressures: Tono-pen v Applanator (Goldmann) Visual Acuity or be a Slit Lamp KWEEN Move outside in: Lids → Eyeball Lids: ducts, eyelashes, orbital lesions or findings EYE:Read more

    • Oh no baby WHAT IS U DOIN’?

      Neonatal Resuscitation. (Some descriptors for reference: Terrifying. Scary. Fear-inducing. Horrific. Chilling.) But fear not! Your TR pearl today is brought to you by the NICU rotation + Jillian Nickerson/T.Webb doing some excellent preparatory work for/withRead more

    • Amanita Muscaria

      For those of you who remember Super Mario Bros… how awesome was it to gobble up that red and white mushroom gliding along the ground and get huge for a few seconds? The result of consuming thisRead more