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This study evaluated safety and efficacy data from 59 critically ill patients with COVID-19 who received tissue plasminogen activator (tPA) for confirmed or suspected pulmonary embolism (PE) within 14 days of ICU admission. Of these patients, 20.3% had radiologically confirmed PE. During hospitalization, 76.3% of patients died. Additionally, 10.2% had a major bleeding complication within the 7 days following tPA administration. There were no changes in in oxygenation, ventilation, or hemodynamic parameters following tPA administration.
The findings of this small, uncontrolled study suggest that critically ill patients with COVID-19 infection who receive tPA experience an increased risk of major bleeding complications similar to risks reported in the literature for other patients administered tPA. The authors noted that there may be an even higher risk when administration is concomitant with therapeutic anticoagulation (which was being administered to 5 of the 6 patients who experienced bleeds). Further research is warranted to determine if there is a subset of COVID-19 patients who may benefit from this therapy.
Hypercoagulability may be a key factor leading to multiorgan failure and death in critically ill patients with coronavirus disease 2019 (COVID-19) (1). Extensive pulmonary microthrombi have been described in patients with acute respiratory distress syndrome from COVID-19 (2, 3). These observations have prompted some clinicians to advocate for use of fibrinolytic therapy with recombinant tissue plasminogen activator (tPA) in select critically ill patients with COVID-19 (4, 5), yet sparse data on safety and efficacy are available (6, 7).
We used data from the Study of the Treatment and Outcomes in Critically Ill Patients with COVID-19 (STOP-COVID), a multicenter cohort study of critically ill adults with COVID-19 admitted to 68 geographically-diverse hospitals across the US, to examine the safety and efficacy of tPA in this setting (8). We included patients from the STOP-COVID registry admitted to ICUs between March 1 and July 1, 2020 who received tPA for confirmed pulmonary embolism (PE) or suspected PE / pulmonary microthrombi within 14 days following ICU admission. Patients were followed until hospital discharge or death.