Reduced-Dose Versus Full-Dose Alteplase for High-Risk Pulmonary Embolism (REDSTEM)
Reduced-Dose Versus Full-Dose Systemic Thrombolysis for High-Risk Pulmonary Embolism: A Multicentre, Randomised, Open-Label, Blinded-Endpoint Trial
High-risk pulmonary embolism is a life-threatening condition requiring immediate reperfusion therapy. Full-dose systemic thrombolysis is recommended as first-line treatment, but its use is limited by the risk of major bleeding, including intracranial hemorrhage. Reduced-dose systemic thrombolysis may reduce bleeding while maintaining clinical efficacy, but this strategy has not been adequately evaluated in patients with high-risk pulmonary embolism.
REDSTEM is an international, multicenter, randomized, adaptive, open-label, blinded-endpoint phase 4 trial comparing reduced-dose alteplase with standard full-dose alteplase in adults with acute high-risk pulmonary embolism. The trial will assess whether reduced-dose alteplase preserves early clinical efficacy while reducing severe clinically significant bleeding. Participants will be followed for up to 12 months.
調査の概要
詳細な説明
Systemic thrombolysis is recommended as first-line reperfusion therapy for high-risk pulmonary embolism. However, bleeding complications limit its use in clinical practice and contribute to undertreatment of eligible patients. Existing evidence from small randomized trials, observational studies, and meta-analyses suggests that lower-dose thrombolysis may improve safety while maintaining efficacy, but previous studies have included mixed-risk pulmonary embolism populations and only a limited number of patients with high-risk pulmonary embolism.
REDSTEM was designed to evaluate whether a reduced-dose alteplase strategy can provide a more favorable balance between efficacy and safety compared with standard full-dose alteplase in patients with high-risk pulmonary embolism. The study uses randomized treatment allocation, blinded endpoint adjudication, independent safety monitoring, and an adaptive design allowing sample-size re-estimation if required.
The trial includes early clinical assessments during the acute phase and follow-up through 12 months to evaluate clinical outcomes, safety, functional recovery, quality of life, and health care resource utilization.
研究の種類
入学 (推定)
段階
- フェーズ 4
連絡先と場所
研究連絡先
- 名前:Kristina Svennerholm, MD PhD
- 電話番号:+46313421000
- メール:kristina.svennerholm@vgregion.se
研究連絡先のバックアップ
- 名前:Annika Odenstedt, Coordinator
- 電話番号:+46313421000
- メール:annika.odenstedt@vgregion.se
研究場所
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Falun、スウェーデン
- Falun Hospital
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コンタクト:
- Jessica Silfverberg, MD
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Gothenburg、スウェーデン
- Sahlgrenska University Hospital/Östra
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コンタクト:
- Katarina Glise Sandblad, MD, PhD
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Jönköping、スウェーデン
- Ryhov County Hospital
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コンタクト:
- Antheia Kissopoulou, MD, PhD
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Lund、スウェーデン
- Skåne University Hospital, Lund
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コンタクト:
- Marcus Ohlsson, MD
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Malmö、スウェーデン
- Skåne University Hospital, Malmö
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コンタクト:
- Marcus Ohlsson, MD, PhD
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Mölndal、スウェーデン
- Sahlgrenska University Hospital/Mölndal
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コンタクト:
- Louise Martinell, MD, PhD
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Norrtälje、スウェーデン
- Norrtälje Hospital
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コンタクト:
- Sune Forsberg, MD, PhD
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Skövde、スウェーデン
- Skaraborgs Hospital Skövde
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コンタクト:
- Freyr Einarsson, MD
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コンタクト:
- Erik Ullemark, MD
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Stockholm、スウェーデン
- Danderyd Hospital
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コンタクト:
- Nina Olausson, MD, PhD
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Stockholm、スウェーデン
- Karolinska University Hospital, Solna
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コンタクト:
- Therese Djärv, MD, PhD
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Stockholm、スウェーデン
- Karolinska University Hospital, Huddinge
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コンタクト:
- Therese Djärv, MD, PhD
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Stockholm、スウェーデン
- Capio S:t Göran's Hospital
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コンタクト:
- Rickard Markgren, MD, PhD
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Stockholm、スウェーデン
- Södersjukhuset, Stockholm South General Hospital
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コンタクト:
- Jacob Hollenberg, MD, PhD
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Umeå、スウェーデン
- University Hospital of Umeå
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コンタクト:
- Johanna Pennlert, MD, PhD
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Uppsala、スウェーデン
- Uppsala University Hospital
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コンタクト:
- Sofia Vikman, MD, PhD
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Västra Götaland County
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Gothenburg、Västra Götaland County、スウェーデン、413 45
- Sahlgrenska University Hospital
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コンタクト:
- Kristina Svennerholm, MD, PhD
- メール:kristina.svennerholm@vgregion.se
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コンタクト:
- Annika Odenstedt
- メール:annika.odenstedt@vgregion.se
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Copenhagen、デンマーク
- Rigshospitalet
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コンタクト:
- Jesper Kjaergaard, MD, PhD
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Bergen、ノルウェー、5021
- Haukeland University Hospital
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コンタクト:
- Lasse Melvear Gii, MD, PhD
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Drammen、ノルウェー、3004
- Drammen Hospital
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コンタクト:
- Jonas Pivoriunas, MD, PhD
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Grålum、ノルウェー、1714
- Ostfold Hisptal
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コンタクト:
- Hans Joakim Myklebust-Hansen, MD
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Lörenskog、ノルウェー、1478
- Akershus University Hospital
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コンタクト:
- Hamza Nahoui, MD
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Oslo、ノルウェー、0450
- Oslo University Hospital, Ullevål
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コンタクト:
- Mari Asphjell Björnaas, MD, PhD
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Stavanger、ノルウェー、4021
- Stavanger University Hospital
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コンタクト:
- Trond Johan Cooper, MD
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参加基準
適格基準
就学可能な年齢
- 大人
- 高齢者
健康ボランティアの受け入れ
説明
Inclusion Criteria:
- Participant aged 18 years or older.
- Acute pulmonary embolism verified by computed tomography pulmonary angiography or pulmonary angiography. In hemodynamically unstable participants unable to undergo immediate imaging, presumed pulmonary embolism may be diagnosed based on bedside echocardiographic findings consistent with acute right ventricular pressure overload and high clinical suspicion of pulmonary embolism, provided that alternative causes of hemodynamic instability have been reasonably excluded. In such cases, the treating clinician must have independently decided to initiate thrombolytic therapy irrespective of study participation, and confirmatory imaging demonstrating pulmonary embolism must be performed as soon as clinically feasible.
High risk for early death, defined by at least one of the following:
High-risk pulmonary embolism according to European Society of Cardiology criteria:
- Cardiac arrest with return of spontaneous circulation;
- Obstructive shock, defined as systolic blood pressure <90 mmHg or use of vasopressors to maintain systolic blood pressure ≥90 mmHg despite adequate filling status, together with end-organ hypoperfusion such as elevated serum lactate >2 mmol/L, altered mental status, or cold clammy skin;
- Persistent hypotension, defined as systolic blood pressure <90 mmHg or a drop in systolic blood pressure ≥40 mmHg for longer than 15 minutes, not caused by new-onset arrhythmia, hypovolemia, or sepsis.
- Abnormal right ventricular function on echocardiography or computed tomography pulmonary angiography, defined as right ventricular/left ventricular ratio ≥1.0, and elevated cardiac troponin above the local upper reference limit, and acute respiratory failure not primarily caused by underlying lung disease, defined as requiring facemask oxygen supplementation ≥12 L/min, high-flow nasal oxygen, or non-invasive ventilation with FiO2 ≥60% to reach oxygen saturation ≥94%.
- Female participants of childbearing potential must have a negative urine or serum pregnancy test.
Exclusion Criteria:
- Catastrophic pulmonary embolism, defined as ongoing cardiac arrest and/or need for extracorporeal cardiopulmonary resuscitation and/or immediate VA-ECMO as judged by the treating physicians.
- Known hypersensitivity to alteplase or any of its excipients.
Contraindication to systemic thrombolysis with one or more of the following:
- History of hemorrhagic stroke;
- Ischemic stroke within the previous 6 months;
- Central nervous system neoplasm;
- Major trauma, major surgery, or major head injury within the previous 3 weeks;
- Active life-threatening bleeding, bleeding into a critical organ or area, or known severe bleeding diathesis;
- Chronic use of full-dose oral or parenteral anticoagulation before presentation.
- The participant has already received reperfusion treatment for the index pulmonary embolism before randomization, including systemic thrombolysis, surgical embolectomy, or catheter-directed intervention.
- Pregnancy.
- Current participation in another study that would interfere with participation in this trial.
- Any other condition that would put the participant at unacceptable risk from the trial interventions as judged by the treating clinician.
- In countries where required by national regulations: lack of affiliation to a social security system or equivalent health insurance coverage.
研究計画
研究はどのように設計されていますか?
デザインの詳細
- 主な目的:処理
- 割り当て:ランダム化
- 介入モデル:並列代入
- マスキング:独身
武器と介入
参加者グループ / アーム |
介入・治療 |
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実験的:Reduced-Dose Alteplase
Participants randomized to reduced-dose systemic thrombolysis will receive alteplase 0.6 mg/kg body weight, up to a maximum dose of 50 mg, administered intravenously over 15 minutes.
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Alteplase 0.6 mg/kg body weight, maximum 50 mg, administered as an intravenous infusion over 15 minutes
他の名前:
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アクティブコンパレータ:Full-Dose Alteplase
Participants randomized to standard full-dose systemic thrombolysis will receive alteplase 1.5 mg/kg body weight, up to a maximum dose of 100 mg, administered as a 10 mg intravenous bolus over 1 to 2 minutes followed by a 90 mg intravenous infusion over 2 hours.
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Alteplase 1.5 mg/kg body weight, maximum 100 mg, administered as a 10 mg intravenous bolus over 1 to 2 minutes followed by 90 mg as an intravenous infusion over 2 hours.
他の名前:
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この研究は何を測定していますか?
主要な結果の測定
結果測定 |
メジャーの説明 |
時間枠 |
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Incidence of composite efficacy endpoint
時間枠:Within 7 days after randomization
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Incidence of a composite endpoint comprising all-cause mortality within 7 days, cardiopulmonary resuscitation and/or veno-arterial extracorporeal membrane oxygenation within 7 days, recurrent pulmonary embolism within 7 days, clinical deterioration within 24 hours, and lack of clinical improvement at 6 hours.
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Within 7 days after randomization
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Key secondary endpoint - Incidence of severe clinically significant bleeding
時間枠:Within 7 days after randomization
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Incidence of severe clinically significant bleeding, defined as major bleeding according to International Society on Thrombosis and Haemostasis criteria or bleeding requiring urgent medical intervention.
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Within 7 days after randomization
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二次結果の測定
結果測定 |
メジャーの説明 |
時間枠 |
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All-cause mortality
時間枠:At 7 days and 30 days after randomization
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Incidence of death from any cause.
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At 7 days and 30 days after randomization
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Pulmonary embolism-related mortality
時間枠:At 7 days and 30 days after randomization
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Incidence of pulmonary embolism-related death.
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At 7 days and 30 days after randomization
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Cardiopulmonary resuscitation and/or VA-ECMO
時間枠:Within 7 days after randomization
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Incidence of cardiopulmonary resuscitation and/or veno-arterial extracorporeal membrane oxygenation.
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Within 7 days after randomization
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Incidence of clinical deterioration
時間枠:Within 24 hours after randomization
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Incidence of life-threatening hemodynamic or respiratory decline requiring cardiopulmonary resuscitation, endotracheal intubation, or VA-ECMO, or an increase in SCAI SHOCK stage after investigational medicinal product administration.
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Within 24 hours after randomization
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Lack of clinical improvement assessed by SCAI SHOCK stage and oxygen requirement
時間枠:At 6 hours after randomization
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Incidence of unchanged SCAI SHOCK stage or unchanged or rising fraction of inspired oxygen required to maintain oxygen saturation of at least 94%.
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At 6 hours after randomization
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Time to clinical stabilization based on predefined hemodynamic and respiratory criteria
時間枠:From randomization until clinical stabilization, assessed up to 7 days after randomization
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Time from randomization to the time point at which predefined hemodynamic or respiratory stabilization criteria have been continuously fulfilled for at least 30 minutes
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From randomization until clinical stabilization, assessed up to 7 days after randomization
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Incidence of recurrent pulmonary embolism
時間枠:At 7 days and 30 days after randomization
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Incidence of objectively confirmed recurrent pulmonary embolism.
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At 7 days and 30 days after randomization
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Initiation of invasive or non-invasive mechanical ventilation
時間枠:Within 7 days after randomization
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Incidence of initiation of invasive or non-invasive mechanical ventilation.
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Within 7 days after randomization
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Win ratio for efficacy
時間枠:Within 7 days after randomization
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Win ratio based on all-cause mortality, cardiopulmonary resuscitation and/or VA-ECMO, clinical deterioration, lack of clinical improvement, recurrent pulmonary embolism, and time to clinical stabilization.
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Within 7 days after randomization
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Net clinical benefit
時間枠:Within 7 days after randomization
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Composite net clinical benefit including severe clinically significant bleeding, all-cause mortality, cardiopulmonary resuscitation and/or VA-ECMO, recurrent pulmonary embolism, clinical deterioration, and lack of clinical improvement.
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Within 7 days after randomization
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Rescue treatment
時間枠:Before clinical stabilization, up to 7 days after randomization
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Need for rescue treatment, defined as additional alteplase, catheter-directed intervention, surgical embolectomy, or VA-ECMO before stabilization.
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Before clinical stabilization, up to 7 days after randomization
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ICU or high-dependency unit length of stay in days
時間枠:Within 30 days after randomization
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Length of stay in intensive care unit and/or high-dependency unit.
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Within 30 days after randomization
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Hospital length of stay
時間枠:Within 30 days after randomization
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Length of hospital stay.
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Within 30 days after randomization
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Major bleeding
時間枠:At 48 hours, 7 days, and 30 days after randomization
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Incidence of major bleeding according to International Society on Thrombosis and Haemostasis criteria.
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At 48 hours, 7 days, and 30 days after randomization
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Bleeding requiring urgent medical intervention
時間枠:At 48 hours, 7 days, and 30 days after randomization
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Incidence of severe bleeding requiring urgent medical intervention.
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At 48 hours, 7 days, and 30 days after randomization
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Intracerebral bleeding
時間枠:Within 7 days after randomization
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Incidence of intracerebral bleeding.
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Within 7 days after randomization
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その他の成果指標
結果測定 |
メジャーの説明 |
時間枠 |
|---|---|---|
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All-cause mortality at 12 months
時間枠:At 12 months after randomization
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Incidence of death from any cause.
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At 12 months after randomization
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At 12 months after randomization
時間枠:At 12 months after randomization
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Incidence of objectively confirmed recurrent pulmonary embolism.
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At 12 months after randomization
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Persistent dyspnea assessed using the modified Medical Research Council scale
時間枠:At 3 months and 12 months after randomization
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Persistent dyspnea assessed using the modified Medical Research Council scale.
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At 3 months and 12 months after randomization
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Functional status assessed using the Post-VTE Functional Status Scale
時間枠:At 3 months and 12 months after randomization
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Functional status assessed using the post-VTE functional status (PVFS) scale.
Scores range from 0 to 4, where 0 indicates no functional limitations and 4 indicates severe functional limitations.
Higher scores indicate worse functional status.
Death before the scheduled assessment is recorded as grade D.
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At 3 months and 12 months after randomization
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Exercise tolerance assessed using the 6-minute walk test
時間枠:At 3 months and 12 months after randomization
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Exercise tolerance assessed using the 6-minute walk test, reported as distance walked in meters.
A greater distance indicates better exercise tolerance.
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At 3 months and 12 months after randomization
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Persistent right ventricular dysfunction assessed by echocardiography
時間枠:At 3 months and/or 12 months after randomization
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Persistent right ventricular dysfunction according to echocardiography report, when performed as clinically indicated.
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At 3 months and/or 12 months after randomization
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Pulmonary embolism-specific quality of life assessed using the PEmb-QoL questionnaire
時間枠:At 3 months and 12 months after randomization
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Pulmonary embolism-specific health-related quality of life assessed using the Pulmonary Embolism Quality of Life (PEmb-QoL) questionnaire.
The PEmb-QoL summary score ranges from 0 to 100, with higher scores indicating worse health-related quality of life.
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At 3 months and 12 months after randomization
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Health-related quality of life assessed using EQ-5D-5L
時間枠:At 3 months and 12 months after randomization
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Health-related quality of life assessed using the EuroQol 5-Dimension 5-Level (EQ-5D-5L) instrument.
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At 3 months and 12 months after randomization
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Chronic thromboembolic pulmonary hypertension
時間枠:At 12 months after randomization
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Incidence of chronic thromboembolic pulmonary hypertension.
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At 12 months after randomization
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Health care resource utilization
時間枠:During 12 months after randomization
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Cost of health care resource utilization during the 12-month follow-up period.
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During 12 months after randomization
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協力者と研究者
協力者
捜査官
- 主任研究者:Kristina Svennerholm、Sahlgrenska University Hospital / University of Gothenburg
出版物と役立つリンク
一般刊行物
- Schulman S, Kearon C; Subcommittee on Control of Anticoagulation of the Scientific and Standardization Committee of the International Society on Thrombosis and Haemostasis. Definition of major bleeding in clinical investigations of antihemostatic medicinal products in non-surgical patients. J Thromb Haemost. 2005 Apr;3(4):692-4. doi: 10.1111/j.1538-7836.2005.01204.x.
- 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.
- Konstantinides SV, Meyer G, Becattini C, Bueno H, Geersing GJ, Harjola VP, Huisman MV, Humbert M, Jennings CS, Jimenez D, Kucher N, Lang IM, Lankeit M, Lorusso R, Mazzolai L, Meneveau N, Ni Ainle F, Prandoni P, Pruszczyk P, Righini M, Torbicki A, Van Belle E, Zamorano JL; ESC Scientific Document Group. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J. 2020 Jan 21;41(4):543-603. doi: 10.1093/eurheartj/ehz405. No abstract available.
- 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.
- Stevens SM, Woller SC, Kreuziger LB, Bounameaux H, Doerschug K, Geersing GJ, Huisman MV, Kearon C, King CS, Knighton AJ, Lake E, Murin S, Vintch JRE, Wells PS, Moores LK. Antithrombotic Therapy for VTE Disease: Second Update of the CHEST Guideline and Expert Panel Report. Chest. 2021 Dec;160(6):e545-e608. doi: 10.1016/j.chest.2021.07.055. Epub 2021 Aug 2.
- Silver MJ, Giri J, Duffy A, Jaber WA, Khandhar S, Ouriel K, Toma C, Tu T, Horowitz JM. Incidence of Mortality and Complications in High-Risk Pulmonary Embolism: A Systematic Review and Meta-Analysis. J Soc Cardiovasc Angiogr Interv. 2023 Jan 27;2(1):100548. doi: 10.1016/j.jscai.2022.100548. eCollection 2023 Jan-Feb.
- Keller K, Hobohm L, Ebner M, Kresoja KP, Munzel T, Konstantinides SV, Lankeit M. Trends in thrombolytic treatment and outcomes of acute pulmonary embolism in Germany. Eur Heart J. 2020 Jan 21;41(4):522-529. doi: 10.1093/eurheartj/ehz236.
- Goldhaber SZ, Agnelli G, Levine MN. Reduced dose bolus alteplase vs conventional alteplase infusion for pulmonary embolism thrombolysis. An international multicenter randomized trial. The Bolus Alteplase Pulmonary Embolism Group. Chest. 1994 Sep;106(3):718-24. doi: 10.1378/chest.106.3.718.
- Melamed R, Tierney DM, Xia R, Brown CS, Mara KC, Lillyblad M, Sidebottom A, Wiley BM, Khapov I, Gajic O. Safety and Efficacy of Reduced-Dose Versus Full-Dose Alteplase for Acute Pulmonary Embolism: A Multicenter Observational Comparative Effectiveness Study. Crit Care Med. 2024 May 1;52(5):729-742. doi: 10.1097/CCM.0000000000006162. Epub 2024 Jan 3.
- Stadlbauer A, Verbelen T, Binzenhofer L, Goslar T, Supady A, Spieth PM, Noc M, Verstraete A, Hoffmann S, Schomaker M, Hopler J, Kraft M, Tautz E, Hoyer D, Tongers J, Haertel F, El-Essawi A, Salem M, Rangel RH, Hullermann C, Kriz M, Schrage B, Moises J, Sabate M, Pappalardo F, Crusius L, Mangner N, Adler C, Tichelbacker T, Skurk C, Jung C, Kufner S, Graf T, Scherer C, Villegas Sierra L, Billig H, Majunke N, Speidl WS, Zilberszac R, Chiscano-Camon L, Uribarri A, Riera J, Roncon-Albuquerque R Jr, Terauda E, Erglis A, Tavazzi G, Zeymer U, Knorr M, Kilo J, Mobius-Winkler S, Schwinger RHG, Frank D, Borst O, Haberle H, De Roeck F, Vrints C, Schmid C, Nickenig G, Hagl C, Massberg S, Schafer A, Westermann D, Zimmer S, Combes A, Camboni D, Thiele H, Lusebrink E; High-risk P. E. Investigator Group. Management of high-risk acute pulmonary embolism: an emulated target trial analysis. Intensive Care Med. 2025 Mar;51(3):490-505. doi: 10.1007/s00134-025-07805-4. Epub 2025 Feb 25.
研究記録日
主要日程の研究
研究開始 (推定)
一次修了 (推定)
研究の完了 (推定)
試験登録日
最初に提出
QC基準を満たした最初の提出物
最初の投稿 (実際)
学習記録の更新
投稿された最後の更新 (実際)
QC基準を満たした最後の更新が送信されました
最終確認日
詳しくは
本研究に関する用語
追加の関連 MeSH 用語
その他の研究ID番号
- REDSTEM
- 2024-515904-37-00 (Ctis)
個々の参加者データ (IPD) の計画
個々の参加者データ (IPD) を共有する予定はありますか?
IPD プランの説明
IPD 共有時間枠
IPD 共有アクセス基準
IPD 共有サポート情報タイプ
- STUDY_PROTOCOL
- SAP
医薬品およびデバイス情報、研究文書
米国FDA規制医薬品の研究
米国FDA規制機器製品の研究
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