Recent guidelines recommend bolus-dose
alteplase for treating massive
pulmonary embolism (PE). However, the safest and most effective treatment is as yet unknown. In the present study, a meta-analysis of published studies of
alteplase infusion, bolus-dose
alteplase and
streptokinase was performed. The outcome measures were as follows: objective assessment of thrombolysis; all-cause mortality; deaths due to initial PE, major
bleeding episodes and recurrent PE; and morbidity. In total, 26 studies were identified; however, only two comparative studies of
alteplase infusion versus either bolus-dose
alteplase or
streptokinase were found. Meta-analysis revealed no significant difference between the three regimens, but was compromised by a paucity of data. Crude analysis of summated data on thrombolytic efficacy from all studies revealed that
alteplase infusion was more effective than bolus-dose
alteplase (relative risk (RR): 1.95; 95% confidence interval (CI): 1.19-3.2), whereas
streptokinase was more effective than
alteplase infusion (RR: 1.27; 95% CI: 1.09-1.47).
Alteplase infusion had a lower mortality due to the initial PE than both bolus-dose
alteplase and
streptokinase (RR: 0.16; 95% CI: 0.05-0.59 and RR: 0.13; 95% CI: 0.04-0.46, respectively). In conclusion, this evidence suggests that the three
thrombolytic agents may vary in efficacy. However, large-scale randomised controlled trials are needed to confirm these results.