Reduced-Dose Thrombolysis in Intermediate-Risk Pulmonary Embolism With High-Risk Features (REDUCTION)
Reduced-Dose Thrombolysis in Intermediate-High Risk Pulmonary Embolism, a Multicenter, Randomized Controlled Trial
Alteplase, a recombinant tissue plasminogen activator (rt-PA), is commonly used for thrombolytic treatment in patients with high-risk acute pulmonary thromboembolism (PTE), whereas the role of thrombolysis in intermediate-risk PTE remains controversial. This multicenter, randomized controlled trial will compare the efficacy and safety of reduced-dose alteplase (25 mg administered intravenously over 2 hours) plus standard anticoagulation with standard anticoagulation alone in patients with intermediate-risk PTE who have high-risk features.
Aperçu de l'étude
Statut
Statut
Les conditions
Les conditions
Intervention / Traitement
Intervention / Traitement
Description détaillée
In patients with intermediate-risk pulmonary embolism (PE), full-dose systemic thrombolysis has been associated with a reduction in the risk of hemodynamic decompensation but an increased risk of major and intracranial bleeding. Previous studies suggest that reduced-dose thrombolysis may improve right ventricular (RV) function while potentially reducing bleeding complications. However, evidence regarding the efficacy and safety of reduced-dose systemic thrombolysis in patients with intermediate risk PE and additional high-risk clinical features remains limited. This study aims to evaluate the efficacy and safety of reduced-dose thrombolytic therapy in this patient population.
The REDUCTION study is a multicenter, randomized, open-label, controlled trial with blinded endpoint assessment and long-term follow-up.
Eligible patients will be randomly assigned in a 1:1 ratio to receive reduced-dose alteplase combined with standard anticoagulation or standard anticoagulation alone. Randomization will be centrally managed and stratified by participating center.
Patients will receive:
- Reduced-dose alteplase group: Alteplase 25 mg administered by intravenous infusion over 2 hours, followed by standard anticoagulation with low-molecular-weight heparin (LMWH) or unfractionated heparin (UFH) for at least 5 days.
- Standard anticoagulation group: Standard anticoagulation with LMWH or UFH for at least 5 days without thrombolytic therapy.
The primary objective is to assess the efficacy of reduced-dose alteplase in improving RV function at 48 hours, as measured by the change in the ratio of right ventricular to left ventricular end-diastolic diameters (RVED/LVED) on echocardiography.
The secondary objectives are to evaluate early changes in right ventricular function, clinical deterioration, PE-related mortality, recurrent PE, and bleeding complications. Long-term assessments will evaluate persistent dyspnea, functional status, persistent right ventricular dysfunction, and the occurrence of chronic thromboembolic pulmonary disease (CTEPD) and chronic thromboembolic pulmonary hypertension (CTEPH)
Type d'étude
Type d'étude
Inscription (Estimé)
Inscription
Phase
Phase
- Phase 3
Contacts et emplacements
Coordonnées de l'étude
Coordonnées de l'étude
- Nom: Changming Xiong, Prof.
- Numéro de téléphone: (+86)010-88396798
- E-mail: xiongcmfw@163.com
Lieux d'étude
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Beijing, Chine, 100037
- Chinese Academy of Medical Sciences, Fuwai Hospital
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Contact:
- Changming Xiong, Prof.
- Numéro de téléphone: 010-88396798
- E-mail: xiongcmfw@163.com
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Beijing Municipality
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Beijing, Beijing Municipality, Chine, 100029
- China-Japan Friendship Hospital
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Contact:
- Zhenguo Zhai
- Numéro de téléphone: 010-84205566
- E-mail: zhaizhenguo2011@126.com
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Beijing, Beijing Municipality, Chine, 100730
- Peking Union Medical College Hospital
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Contact:
- Juhong Shi, Prof.
- Numéro de téléphone: 010-69156114
- E-mail: shijh@pumch.cn
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Beijing, Beijing Municipality, Chine, 100029
- Beijing Anzhen Hospital, Capital Medical University
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Contact:
- Jun Wan, Prof.
- Numéro de téléphone: 010-64412431
- E-mail: blueswan2013@yahoo.com
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Beijing, Beijing Municipality, Chine, 100020
- Beijing ChaoYang Hospital.Capital Medical University
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Contact:
- Yuanhua Yang, Prof.
- Numéro de téléphone: 010-85231777
- E-mail: yyh1031@sina.com
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Guangdong
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Guangzhou, Guangdong, Chine, 510120
- Guangdong Provincial Hospital of Chinese Medicine
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Contact:
- Yinji Xu, Prof.
- Numéro de téléphone: 020-81887233
- E-mail: xuyinji@163.com
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Guangzhou, Guangdong, Chine, 510120
- The First Affiliated Hospital of Guangzhou Medical University / Guangzhou Institute of Respiratory Health (National Clinical Research Center for Respiratory Disease)
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Contact:
- Nuofu Zhang, Prof.
- Numéro de téléphone: 020-83062114
- E-mail: nfzhanggird@163.com
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Shenzhen, Guangdong, Chine, 518116
- Longgang Central Hospital of Shenzhen
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Contact:
- Siliang Xu, Prof.
- Numéro de téléphone: 0755-84806933
- E-mail: 420814562@qq.com
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Hebei
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Zhangjiakou, Hebei, Chine, 075000
- The First Affiliated Hospital of Hebei North University
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Contact:
- Baoli Xiang, Prof.
- Numéro de téléphone: 0313-8043555
- E-mail: 15530396731@163.com
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Henan
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Xinxiang, Henan, Chine, 453400
- HeNan Honliv Hospital
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Contact:
- Lei Yang, Prof.
- Numéro de téléphone: 0373-8882288
- E-mail: 61194255@qq.com
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Zhengzhou, Henan, Chine, 450052
- The First Affiliated Hospital of Zhengzhou University
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Contact:
- Zhe Cheng, Prof.
- Numéro de téléphone: 0371-66913114
- E-mail: chengzhehi@126.com
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Zhengzhou, Henan, Chine, 450003
- Henan Provincial People's Hospital
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Contact:
- Yong Qi, Prof.
- Numéro de téléphone: 0371-65580014
- E-mail: srmyy123@163.com
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Hubei
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Wuhan, Hubei, Chine, 430015
- Wuhan Sixth Hospital (Affiliated Hospital of Jianghan University)
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Contact:
- Fajiu Li, Prof.
- Numéro de téléphone: 027-82426502
- E-mail: 80670519@qq.com
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Inner Mongolia
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Baotou, Inner Mongolia, Chine, 014010
- Inner Mongolia Baogang Hospital
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Contact:
- Hongjun Tian, Prof.
- Numéro de téléphone: 0472-5992811
- E-mail: 1139717960@qq.com
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Tongliao, Inner Mongolia, Chine, 028000
- NMG Keerqin District Hosp.
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Contact:
- Xili Wang, Prof.
- Numéro de téléphone: 0475-8232510
- E-mail: 861004223@qq.com
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Jiangsu
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Changzhou, Jiangsu, Chine, 213003
- The Second People's Hospital of Changzhou, The Third Affiliated Hospital of Nanjing Medical University
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Contact:
- Qian Zhang, Prof.
- Numéro de téléphone: 0519-81099988
- E-mail: kezhang0601@163.com
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Nanjing, Jiangsu, Chine, 210006
- Nanjing First Hospital
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Contact:
- He Xu, Prof.
- Numéro de téléphone: 025-52271000
- E-mail: hexunj@163.com
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Liaoning
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Shenyang, Liaoning, Chine, 110024
- Central Hospital Affiliated to Shenyang Medical College
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Contact:
- Shuyue Xia, Prof.
- Numéro de téléphone: 024-85715200
- E-mail: syx262@126.com
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Shenyang, Liaoning, Chine, 110003
- General Hospital of Northern Theater Command
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Contact:
- Liang Shi, Prof.
- Numéro de téléphone: 024-28886666
- E-mail: 13309889463@163.com
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Ningxia
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Yinchuan, Ningxia, Chine, 750004
- Ningxia Medical University General Hospital
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Contact:
- Juan Chen, Prof.
- Numéro de téléphone: 0951-6744457
- E-mail: chenjuan7419@163.com
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Shandong
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Jinan, Shandong, Chine, 250021
- Shandong Provincial Hospital
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Contact:
- Ling Zhu, Prof.
- Numéro de téléphone: 0531-87938911
- E-mail: zhuling7103@163.com
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Linyi, Shandong, Chine, 276000
- Linyi People's Hospital
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Contact:
- Le Kang, Prof.
- Numéro de téléphone: 0539-8616398
- E-mail: 593119267@qq.com
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Shanghai Municipality
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Shanghai, Shanghai Municipality, Chine, 200120
- Shanghai East Hospital, School of Medicine, Tongji University
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Contact:
- Yingqun Ji, Prof.
- Numéro de téléphone: 021-38804518
- E-mail: jiyingqun@163.com
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Sichuan
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Chengdu, Sichuan, Chine, 610041
- West China Hospital, Sichuan University
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Contact:
- Maojun Wang, Prof.
- Numéro de téléphone: 028-85422114
- E-mail: wmmyun@hotmail.com
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Tianjin Municipality
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Tianjin, Tianjin Municipality, Chine, 300052
- Tianjin Medical University General Hospital
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Contact:
- Lixia Dong, Prof.
- Numéro de téléphone: 022-96580
- E-mail: 18355193818@163.COM
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Tianjin, Tianjin Municipality, Chine, 300222
- Tianjin Chest Hospital
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Contact:
- Songtao Gu
- Numéro de téléphone: 022-88185111
- E-mail: gusongtaodoctor@126.com
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Critères de participation
Critère d'éligibilité
Critère d'éligibilité
Âges éligibles pour étudier
Accepte les volontaires sains
Sexes éligibles pour l'étude
La description
Inclusion Criteria:
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Age 18 to 75 years
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Objectively confirmed acute pulmonary thromboembolism (PTE) with symptom onset within 14 days, based on at least one of the following:
- Ventilation/perfusion lung scan showing at least one segmental or larger mismatched perfusion defect;
- Computed tomography pulmonary angiography (CTPA) or pulmonary angiography showing a filling defect or abrupt obstruction in a segmental or more proximal pulmonary artery.
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Intermediate-high-risk PTE, with both of the following:
- Right ventricular dysfunction (RVD) on echocardiography or CTPA. Echocardiographic RVD is defined by at least one of the following:(1) right ventricular dilation with RV/LV end-diastolic diameter ratio >1.0; (2) reduced right ventricular free-wall motion; (3) increased tricuspid regurgitation velocity;(4) tricuspid annular plane systolic excursion <16 mm; (5) tricuspid annular systolic velocity (S') <9.5 cm/s. CTPA evidence of RVD is defined as right ventricular dilation with RV/LV end-diastolic diameter ratio >1.0.
- Cardiac injury or heart failure biomarker above the local upper limit of normal, including cardiac troponin, BNP, or NT-proBNP.
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Elevated risk of early death/hemodynamic collapse, indicated by at least one of the following high-risk features: Systolic blood pressure ≤110 mmHg, Heart rate ≥100 beats/min, Oxygen saturation (SpO₂) <90% (respiratory rate >20 breaths/min or arterial partial pressure of oxygen [PaO₂] <60 mmHg).
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Signed informed consent
Exclusion Criteria:
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High-risk PTE with hemodynamic instability, including cardiac arrest, obstructive shock, or persistent hypotension defined as systolic blood pressure <90 mmHg or a decrease of ≥40 mmHg from baseline lasting at least 15 minutes, after excluding hypotension caused by new-onset arrhythmia, hypovolemia, or sepsis.
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Intermediate-low-risk PTE, defined as hemodynamically stable PE with only one of the following findings: right ventricular dysfunction on imaging or elevated cardiac biomarkers.
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Low-risk PTE, defined as hemodynamically stable PTE without right ventricular dysfunction and without elevated cardiac injury or heart failure biomarkers.
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Any contraindication to systemic thrombolysis, including:
- Known hypersensitivity to alteplase, gentamicin, heparin, low-molecular-weight heparin, or any component of the study treatment;
- Active bleeding or high risk of bleeding;
- Known or suspected intracranial hemorrhage;
- Suspected subarachnoid hemorrhage or aneurysmal subarachnoid hemorrhage;
- Significant bleeding disorder within the previous 6 months;
- Known bleeding diathesis;
- Acute ischemic stroke or transient ischemic attack within the previous 6 months;
- Ophthalmic surgery within the previous 3 months, or abdominal, cardiac, thoracic, vascular, or orthopedic surgery or trauma within the previous 3 months;
- History of central nervous system disease or trauma, including tumor, aneurysm, head trauma, intracranial surgery, or spinal surgery;
- Platelet count <100 × 10^9/L;
- International normalized ratio (INR) >1.3;
- Current effective oral anticoagulant treatment;
- Traumatic cardiopulmonary resuscitation;
- Infective endocarditis or pericarditis;
- Acute pancreatitis;
- Noncompressible vascular puncture;
- Severe uncontrolled hypertension, with systolic blood pressure >180 mmHg and/or diastolic blood pressure >110 mmHg;
- Any other condition considered by the investigator to confer a high bleeding risk;
- Severe liver disease, including liver failure, cirrhosis, portal hypertension, esophageal varices, or active hepatitis;
- Gastrointestinal ulcer, esophageal varices, arterial aneurysm, or arteriovenous malformation within the previous 3 months;
- Tumor with bleeding tendency;
- Pregnancy or within 1 week postpartum;
- Diabetes with hemorrhagic retinopathy;
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Body weight ≤40 kg.
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Thrombolytic treatment within 30 days before randomization for the current episode of acute PE, including systemic or catheter-directed thrombolysis.
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Catheter-directed mechanical thrombectomy or surgical pulmonary embolectomy before randomization for the current episode of acute PE.
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Use of any direct oral anticoagulant within 30 days before randomization.
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Current dual antiplatelet therapy.
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Current participation in another interventional clinical trial.
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Women of childbearing potential who are unwilling to use effective contraception or abstinence during the study.
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Any other disease or condition that, in the investigator's judgment, would increase treatment risk.
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Life expectancy <3 months or inability to complete 3-month follow-up.
Plan d'étude
Comment l'étude est-elle conçue ?
Détails de conception
- Objectif principal: Traitement
- Répartition: Randomisé
- Modèle interventionnel: Affectation parallèle
- Masquage: Seul
Nombre de bras
Armes et Interventions
Groupe de participants / BrasGroupe de participants / Bras |
Intervention / TraitementIntervention / Traitement |
|---|---|
|
Comparateur actif: Reduced-Dose Alteplase and Standard Anticoagulation
Low-molecular-weight heparin (LMWH) or unfractionated heparin (UFH) and reduced-dose alteplase [25 mg continuous intravenous infusion for 2 hours] |
Alteplase 25 mg will be administered by continuous intravenous infusion over 2 hours Standard anticoagulation will consist of LMWH or UFH administered according to current guideline recommendations for at least 5 days |
|
Comparateur actif: Standard Anticoagulation
Low-molecular-weight heparin (LMWH) or unfractionated heparin (UFH) |
Standard anticoagulation will consist of LMWH or UFH administered according to current guideline recommendations for at least 5 days |
Que mesure l'étude ?
Principaux critères de jugement
Principaux critères de jugement
Mesure des résultats |
Délai |
|---|---|
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Change in the ratio of right ventricular end-diastolic diameter to left ventricular end-diastolic diameter (RVED/LVED) as measured by echocardiography
Délai: Between baseline and 48 hours
|
Between baseline and 48 hours
|
Mesures de résultats secondaires
Mesures de résultats secondaires
Mesure des résultats |
Description de la mesure |
Délai |
|---|---|---|
|
Change in the ratio of right ventricular end-diastolic diameter to left ventricular end-diastolic diameter (RVED/LVED) as measured by echocardiography
Délai: Between baseline and 7 days
|
Between baseline and 7 days
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|
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Clinical Deterioration
Délai: 7 days
|
7 days
|
|
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PE-Related Death
Délai: 7 days
|
Death caused by pulmonary embolism (PE) |
7 days
|
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All cause Death
Délai: 7 days
|
7 days
|
|
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Recurrent PE
Délai: 7 days
|
7 days
|
|
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Persistent Dyspnea
Délai: 6 months
|
Persistent Dyspnea Assessed by the Medical Research Council (MRC) Dyspnea Scale |
6 months
|
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Functional outcome
Délai: 6 months
|
Functional status will be assessed using the Post-Venous Thromboembolism Functional Status (PVFS) Scale, which measures limitations in usual activities and daily functioning after venous thromboembolism. The scale ranges from grade 0 (no functional limitations) to grade 4 (severe functional limitations requiring assistance with activities of daily living). Higher grades indicate greater functional impairment. Grade D indicates death before the scheduled assessment. |
6 months
|
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Persistent Right Ventricular Dysfunction
Délai: 6 months
|
Persistent right ventricular dysfunction is defined as an intermediate or high probability of pulmonary hypertension on echocardiography according to the European Society of Cardiology (ESC) criteria. |
6 months
|
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Chronic thromboembolic pulmonary disease (CTEPD) and/or Chronic thromboembolic pulmonary hypertension (CTEPH)
Délai: 12 months
|
12 months
|
|
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Major bleeding
Délai: 30 days
|
Major bleeding will be defined according to the International Society on Thrombosis and Haemostasis (ISTH) criteria as fatal bleeding, symptomatic bleeding in a critical area or organ, a decrease in hemoglobin of ≥2 g/dL, or transfusion of ≥2 units of whole blood or red blood cells. The number of participants experiencing major bleeding will be recorded |
30 days
|
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Clinically relevant non-major bleeding
Délai: 30 days
|
Clinically relevant non-major bleeding will be defined according to ISTH criteria as bleeding that does not meet the criteria for major bleeding but requires medical intervention, leads to hospitalization or an increased level of care, or prompts a face-to-face evaluation by a healthcare professional. The number of participants experiencing clinically relevant non-major bleeding will be recorded. |
30 days
|
|
Minor bleeding
Délai: 30 days
|
Minor bleeding will be defined as any overt bleeding event that does not meet the criteria for major bleeding or clinically relevant non-major bleeding and does not require medical attention. The number of participants experiencing minor bleeding will be recorded. |
30 days
|
Collaborateurs et enquêteurs
Parrainer
Parrainer
Les enquêteurs
Les enquêteurs
- Chercheur principal: Changming Xiong, Prof., Chinese Academy of Medical Sciences, Fuwai Hospital
- Chercheur principal: Zhenguo Zhai, Prof., China-Japan Friendship Hospital
Publications et liens utiles
Publications générales
- Sharifi M, Bay C, Skrocki L, Rahimi F, Mehdipour M; "MOPETT" Investigators. Moderate pulmonary embolism treated with thrombolysis (from the "MOPETT" Trial). Am J Cardiol. 2013 Jan 15;111(2):273-7. doi: 10.1016/j.amjcard.2012.09.027. Epub 2012 Oct 24.
- Meyer G, Vicaut E, Danays T, Agnelli G, Becattini C, Beyer-Westendorf J, Bluhmki E, Bouvaist H, Brenner B, Couturaud F, Dellas C, Empen K, Franca A, Galie N, Geibel A, Goldhaber SZ, Jimenez D, Kozak M, Kupatt C, Kucher N, Lang IM, Lankeit M, Meneveau N, Pacouret G, Palazzini M, Petris A, Pruszczyk P, Rugolotto M, Salvi A, Schellong S, Sebbane M, Sobkowicz B, Stefanovic BS, Thiele H, Torbicki A, Verschuren F, Konstantinides SV; PEITHO Investigators. Fibrinolysis for patients with intermediate-risk pulmonary embolism. N Engl J Med. 2014 Apr 10;370(15):1402-11. doi: 10.1056/NEJMoa1302097.
- Wang C, Zhai Z, Yang Y, Wu Q, Cheng Z, Liang L, Dai H, Huang K, Lu W, Zhang Z, Cheng X, Shen YH; China Venous Thromboembolism (VTE) Study Group. Efficacy and safety of low dose recombinant tissue-type plasminogen activator for the treatment of acute pulmonary thromboembolism: a randomized, multicenter, controlled trial. Chest. 2010 Feb;137(2):254-62. doi: 10.1378/chest.09-0765. Epub 2009 Sep 9.
- Sanchez O, Charles-Nelson A, Ageno W, Barco S, Binder H, Chatellier G, Duerschmied D, Empen K, Ferreira M, Girard P, Huisman MV, Jimenez D, Katsahian S, Kozak M, Lankeit M, Meneveau N, Pruszczyk P, Petris A, Righini M, Rosenkranz S, Schellong S, Stefanovic B, Verhamme P, de Wit K, Vicaut E, Zirlik A, Konstantinides SV, Meyer G; PEITHO-3 Investigators. Reduced-Dose Intravenous Thrombolysis for Acute Intermediate-High-risk Pulmonary Embolism: Rationale and Design of the Pulmonary Embolism International THrOmbolysis (PEITHO)-3 trial. Thromb Haemost. 2022 May;122(5):857-866. doi: 10.1055/a-1653-4699. Epub 2021 Oct 31.
- Liu L, Li C, Shi L, Ma D, Zhang Z, Bao H, Li C, Li L, Wang M, Ma Z, Zhang J. Efficacy and safety of low-dose thrombolysis in acute intermediate-high risk pulmonary thromboembolism complicated by PaO2/FiO2 < 300. Front Med (Lausanne). 2026 Jul 9;13:1849541. doi: 10.3389/fmed.2026.1849541. eCollection 2026.
- Yilmaz ES, Uzun O. Low-dose thrombolysis for submassive pulmonary embolism. J Investig Med. 2021 Dec;69(8):1439-1446. doi: 10.1136/jim-2021-001816. Epub 2021 Jun 7.
- Zhang LY, Gao BA, Jin Z, Xiang GM, Gong Z, Zhang TT, Lu HF, Wang YQ, Gong Y, Lu C, Huang WL. Clinical efficacy of low dose recombinant tissue-type plasminogen activator for the treatment of acute intermediate-risk pulmonary embolism. Saudi Med J. 2018 Nov;39(11):1090-1095. doi: 10.15537/smj.2018.11.22717.
Dates d'enregistrement des études
Dates principales de l'étude
Début de l'étude (Estimé)
Début de l'étude
Achèvement primaire (Estimé)
Achèvement primaire
Achèvement de l'étude (Estimé)
Achèvement de l'étude
Dates d'inscription aux études
Première soumission
Première soumission
Première soumission répondant aux critères de contrôle qualité
Première soumission répondant aux critères de contrôle qualité
Première publication (Réel)
Première publication
Mises à jour des dossiers d'étude
Dernière mise à jour publiée (Réel)
Dernière mise à jour publiée
Dernière mise à jour soumise répondant aux critères de contrôle qualité
Dernière mise à jour soumise répondant aux critères de contrôle qualité
Dernière vérification
Dernière vérification
Plus d'information
Termes liés à cette étude
Termes MeSH pertinents supplémentaires
- Maladies vasculaires
- Maladies cardiovasculaires
- Maladies des voies respiratoires
- Maladies pulmonaires
- Embolie et thrombose
- Embolie
- Embolie pulmonaire
- Acides aminés, peptides et protéines
- Protéines
- Facteurs biologiques
- Hydrolases
- Enzymes
- Enzymes et coenzymes
- Protéines sanguines
- Endopeptidases
- Hydrolases peptidiques
- Sérine endopeptidases
- Sérine protéases
- Activateurs de plasminogène
- Facteurs de coagulation sanguine
- Activateur tissulaire du plasminogène
Autres numéros d'identification d'étude
Autres numéros d'identification d'étude
- 2026ZD0556203-02
- 2026ZD0556203 (Autre subvention/numéro de financement: Noncommunicable Chronic Diseases-National Science and Technology Major Project)
Plan pour les données individuelles des participants (IPD)
Prévoyez-vous de partager les données individuelles des participants (DPI) ?
Informations sur les médicaments et les dispositifs, documents d'étude
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