Should thrombolysis and sildenafil be given in the acute management of patients with large pulmonary embolism? An assessment of the short and long-term outcomes

Introduction: The role of thrombolysis in the management of patients with haemodynamic compromise in the presence of pulmonary embolism (PE) is recognised although it is unclear whether there is an indication for concomitant use of advanced pulmonary vasodilator therapy. Aims: To assess the potential benefit of sildenafil on outcome when administered acutely with, or without thrombolysis, to patients with large PE. Method: We performed a retrospective review of the outcome of 20 consecutive patients (9 male, 11 female) who presented with acute right heart strain on echocardiographic assessment, computed tomography or biochemical markers (beta natriuretic peptide), in association with large PE, between January 2015–June 2017, who received sildenafil (25mg TDS) at the time of presentation, with or without thrombolysis. Results: Sildenafil was tolerated without complication in 19 patients. There were 2 deaths due to malignancy at 10, and 18 months, and no deaths directly attributable to thromboembolic disease. Of those with calculable pulmonary arterial systolic pressures (PASP) (n=12), the average reduction in PASP at 3-6 months and 12-24 months was -22.04mmHg, and -17.25mmHg respectively. Those receiving sildenafil alone had a greater average reduction in PASP at short and long term follow up (-24.13mmHg, and -25.44mmHg respectively) compared with those also receiving thrombolysis due to haemodynamic compromise (-17.88mmHg, and -1.67mmHg respectively). Our experience suggests that sildenafil can be used safely in this patient group with good haemodynamic outcome, although larger randomised trials are necessary to support this.