Pulmonary embolism: long-term follow-up after treatment with full-dose heparin, streptokinase or embolectomy

The study comprises 74 patients alive 30 days after the start of treatment of pulmonary embolism with heparin (n = 32), streptokinase (n = 22) or embolectomy (n = 20). The cumulative 5-year survival was 100% in the embolectomy group, compared to 75 +/- 7% (SE) in the medically treated patients (p less than 0.05). Cancer caused 78% of the late deaths. At follow-up 0.5-8.7 years after treatment the treatment groups were indistinguishable as regards right-sided heart catheterization data, pulmonary artery rest-obstruction, right ventricular diameter and wall thickness, ventilatory function and ECG changes. The embolectomized patients were in a more favourable NYHA classification level than the medically treated. Chronic pulmonary artery hypertension was found in 75% of patients with greater than or equal to 3 anamnestic recurrent embolic episodes before diagnosis compared to 8% of patients with less than or equal to 2 recurrent episodes (p less than 0.001). Patients with irreversible cardiocirculatory shock before embolectomy all had abnormal pulmonary vascular resistance (greater than 1.5 mmHg/l/min), depressed ventilatory function and more than 25% reduced pulmonary perfusion at follow-up. The major prognostic factors thus were cancer, the number of recurrent episodes and the degree of cardiocirculatory affection in the acute event. Although the embolectomized patients were the most affected initially, they had a good prognosis. This led us to extend our indications for embolectomy to include all patients with central emboli, irrespective of the degree of cardiocirculatory impairment.