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Comment & Response |

Benefits and Risks Associated With Thrombolysis for Pulmonary Embolism

Mark A. Bradford, MD1; Neill K. J. Adhikari, MDCM, MSc2; Jan O. Friedrich, MD, DPhil3
[+] Author Affiliations
1Section of Pulmonary and Critical Care Medicine, Boston University School of Medicine, Boston, Massachusetts
2Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
3Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
JAMA. 2014;312(15):1588-1589. doi:10.1001/jama.2014.10780.
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To the Editor Dr Chatterjee and colleagues1 performed a meta-analysis comparing thrombolysis with anticoagulation for pulmonary embolism using the Peto method to determine pooled odds ratios (ORs) because of low expected event rates among included trials. We suggest that this method is flawed for several reasons.

First, although simulation suggests that the Peto method may outperform standard Mantel-Haenszel OR estimates when event rates are less than 1%,2 the overall risk of mortality after pulmonary embolism is higher (approximately 3%). The Peto method may produce biased estimates with higher events rates.2 Second, the Peto and other methods ignore trials with zero events, creating another source of bias away from no effect.3 Third, the Peto fixed-effects model assumes that included studies measured a single underlying effect. It seems unlikely that thrombolytic trials spanning more than 30 years and using different selection criteria and outcome measures would generate 1 treatment effect.

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October 15, 2014
Saurav Chatterjee, MD; Jay Giri, MD, MPH
1Division of Cardiology, St Luke’s-Roosevelt Hospital, New York, New York
2Cardiovascular Medicine Division, University of Pennsylvania Perelman School of Medicine, Philadelphia
JAMA. 2014;312(15):1589-1590. doi:10.1001/jama.2014.10789.
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