Twenty-six studies were included: 16 RCTs (1,284 participants), 7 prospective studies (274 participants), 2 retrospective studies (153 participants) and 1 case study (6 participants).
Thrombolysis was not assessed for alteplase intravenous infusion versus bolus dose (2 RCTs). No significant differences in any other outcomes were observed between the two treatment groups.
There was no difference in all-cause mortality between alteplase infusion and streptokinase (RR 1.00, 95% CI: 0.07, 15.12, p=1.0; 2 RCTs). When an additional retrospective study was included, alteplase was associated with a trend towards greater incidence of major bleeding (RR 2.07, 95% CI: 0.8, 5.3, p=0.13).
Alteplase infusion was more effective than urokinase for thrombolysis (RR 1.32, 95% CI: 1.05, 1.67, p=0.02; 2 RCTs). The pooled analysis showed that all-cause mortality was similar for alteplase infusion compared with all other treatments combined (RR 1.34, 95% CI: 0.57, 3.14, p=0.7; 8 studies).
When data from cohorts on the same drug were combined and the results compared with those from different studies, alteplase infusion achieved thrombolysis in more cases than bolus dose alteplase (RR 1.95 95% CI: 1.19, 3.2, p=0.008; NNT 3). Streptokinase achieved thrombolysis in more cases than alteplase bolus dose (RR 2.48, 95% CI: 1.52, 4.03, p=0.0003) and alteplase infusion (RR 1.27, 95% CI: 1.09, 1.47, p=0.002; NNT=6). Alteplase infusion had a lower mortality from initial PE than either bolus dose alteplase or streptokinase (RR 0.16, 95% CI: 0.05, 0.59, p=0.005 and RR 0.13, 95% CI: 0.04, 0.46, p=0.001, respectively).