Alteplase/heparin/low-molecular-weight-heparins

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An event is serious (based on the ICH definition) when the patient outcome is:

• * death

• * life-threatening

• * hospitalisation

• * disability

• * congenital anomaly

• * other medically important event

In a study, five men aged 41−67 years were described, who exhibited lack of efficacy or developed jugular and/or femoral haemorrhage following treatment with alteplase, norepinephrine, heparin or unspecified low-molecular weight heparin [duration of treatments to reactions onset not stated; not all routes, dosages and outcomes stated].

Patient 1: The 67-year-old man with severe coronavirus 2 (SARS-CoV-2) pneumonia was managed in the ICU. Imaging showed acute cor pulmonale (ACP), and he was suspected to have PE. He received norepinephrine. Further, he had cardiac arrest. Hence, he received systemic fibrinolysis using IV alteplase 100mg and anti-coagulation treatment with unspecified low-molecular weight heparin. However, return of spontaneous circulation was not achieved, and he died.

Patient 2: The 41-year-old man with severe coronavirus 2 (SARS-CoV-2) pneumonia was managed in the ICU. Imaging showed ACP, and he was suspected to have PE. He received norepinephrine. Further, he had cardiac arrest. Hence, he received systemic fibrinolysis using IV alteplase 100mg and anti-coagulation treatment with unspecified low-molecular weight heparin. However, return of spontaneous circulation was not achieved, and he died.

Patient 3: The 63-year-old man with severe coronavirus 2 (SARS-CoV-2) pneumonia was managed in the ICU. Imaging showed ACP, and he was suspected to have PE. Further, he developed obstructive shock. Hence, he received systemic fibrinolysis using IV alteplase 100mg and anti-coagulation treatment with unspecified low-molecular weight heparin. He also received norepinephrine. Shortly after fibrinolysis, an improvement was observed in obstructive shock, following which norepinephrine dose was decreased. Thereafter, his anti-coagulation treatment was changed to heparin [unfractionated heparin]. Subsequently, he had second episode of obstructive collapse. He again received systemic fibrinolysis using IV alteplase 100mg. However, his shock persisted. After 2 days, he died.

Patient 4: The 55-year-old man with severe coronavirus 2 (SARS-CoV-2) pneumonia was managed in the ICU. Imaging showed ACP, and he was suspected to have PE. He received norepinephrine. Further, he developed obstructive shock. Hence, he received systemic fibrinolysis using IV alteplase 100mg and anti-coagulation treatment with unspecified low-molecular weight heparin. However, his shock persisted. He also developed femoral haemorrhage, for which he received RBC transfusion. Three days later, he died.

Patient 5: The 48-year-old man with severe coronavirus 2 (SARS-CoV-2) pneumonia was managed in the ICU. Imaging showed ACP, and he was suspected to have PE. He started receiving anti-coagulation treatment with heparin. Further, he developed obstructive shock. Hence, he received systemic fibrinolysis using alteplase along with norepinephrine. Shortly after fibrinolysis, an improvement was observed in obstructive shock, following which norepinephrine dose was decreased. Subsequently, he developed jugular and femoral haemorrhage. He was treated with three RBC transfusions.