Thrombolytics for venous thromboembolic events: a systematic review with meta-analysis.

Thrombolytic therapy might reduce venous thromboembolism-related mortality and morbidity, but it could also increase the risk of major bleeding. We systematically reviewed the literature to evaluate the effectiveness and safety of thrombolytics in patients with pulmonary embolism (PE) and/or deep venous thrombosis (DVT). We searched Medline, Embase, and Cochrane databases for relevant randomized controlled trials up to February 2019. Multiple investigators independently screened and collected data. We included 45 studies (4740 participants). Pooled estimates of PE studies indicate probable reduction in mortality with thrombolysis (risk ratio [RR], 0.61; 95% confidence interval [CI], 0.40-0.94) (moderate certainty) and possible reduction in nonfatal PE recurrence (RR, 0.56; 95% CI, 0.35-0.89) (low certainty). Pooled estimates of DVT studies indicate the possible absence of effects on mortality (RR, 0.77; 95% CI, 0.26-2.28) (low certainty) and recurrent DVT (RR, 0.99; 95% CI, 0.56-1.76) (low certainty), but possible reduction in postthrombotic syndrome (PTS) with thrombolytics (RR, 0.70; 95% CI, 0.59-0.83) (low certainty). Pooled estimates of the complete body of evidence indicate increases in major bleeding (RR, 1.89; 95% CI, 1.46-2.46) (high certainty) and a probable increase in intracranial bleeding (RR, 3.17; 95% CI 1.19-8.41) (moderate certainty) with thrombolytics. Our findings indicate that thrombolytics probably reduce mortality in patients with submassive- or intermediate-risk PE and may reduce PTS in patients with proximal DVT at the expense of a significant increase in major bleeding. Because the balance between benefits and harms is profoundly influenced by the baseline risks of critical outcomes, stakeholders involved in decision making would need to weigh these effects to define which clinical scenarios merit the use of thrombolytics.

Falsely elevated international normalized ratio values in patients undergoing anticoagulation therapy: a descriptive evaluation.

BACKGROUND: Elevated international normalized ratio (INR) values have been linked to bleeding complications; however, elevated INR values are not always physiologic and can be falsely increased. This study describes the rate of falsely elevated INRs and characteristics predictive of falsely elevated INRs. METHODS: This cross-sectional study was conducted among adult patients receiving anticoagulation therapy monitored by a centralized anticoagulation service during January 2000 through December 2004 (n = 29,536). Prevalence rates of all elevated (ie, value >/= 10), falsely elevated, and truly elevated INRs were calculated. Multivariate logistic regression was performed to identify predictors of falsely elevated INRs among elevated INRs. RESULTS: Of the 556,998 INRs included in the analysis, 793 INRs (prevalence, 0.14%; 95% confidence interval [CI], 0.10 to 0.19%), 53 INRs (prevalence, 0.01%; 95% CI, < 0.01 to 0.03%), and 740 INRs (prevalence, 0.13%; 95% CI, 0.09 to 0.18%) were elevated, falsely elevated, and truly elevated, respectively. The strongest independent predictor of a falsely elevated INR was a patient undergoing hemodialysis at the time of the elevated INR (adjusted odds ratio, 9.60; 95% CI, 4.96 to 18.58; p < 0.001). A low target INR was the only other factor found to be an independent predictor of a falsely elevated INR. CONCLUSIONS: Although INR values >/= 10.0 occur infrequently, patients presenting with such values can present a challenge to the anticoagulation provider. Anticoagulation providers should be particularly vigilant for falsely elevated INRs when monitoring patients undergoing hemodialysis.