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Aktuelle Therapie und Sekundärprävention der Lungenembolie

Current therapy and secondary prophylaxis of pulmonary embolism

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Zusammenfassung

Die Strategien zur Risikostratifizierung und risikoadaptierten Diagnostik und Therapie von Patienten mit Lungenembolie befinden sich aktuell in einer Phase des Umbruchs. Für die neuen europäischen Leitlinien, die im Jahr 2014 erscheinen sollen, werden umfangreiche Veränderungen insbesondere im Bereich der Indikation zur Thrombolyse bei normotensiven Patienten mit „intermediärem“ Risiko, der interventionellen Hybridverfahren zur pharmakomechanischen lokalen Thrombolyse, der neuen oralen Antikoagulanzien zur Therapie und (verlängerten) Sekundärprophylaxe, der möglichen Indikation von Azetylsalizylsäure zur verlängerten Sekundärprophylaxe sowie der ambulanten Behandlung von Patienten mit „niedrigem“ Risiko erwartet. In diesem Artikel werden die aktuellen Leitlinien zur Therapie und Sekundärprävention der Lungenembolie sowie die aktuelle klinische Studienlage und deren mögliche Implikationen für die Therapie und die Sekundärprävention der Lungenembolie zusammengefasst.

Abstract

Currently strategies for risk stratification and risk-adjusted diagnostics and management algorithms of patients with pulmonary embolism are undergoing considerable progress and transition. For the new European guidelines expected in 2014, extensive changes are expected in the areas of (1) thrombolysis of normotensive patients with intermediate risk, (2) interventional ultrasound-enhanced low-dose catheter-derived (pharmacomechanical) local thrombolysis, (3) novel oral anticoagulants for therapy and (extended) secondary prophylaxis, (4) possible indications of low-dose aspirin for extended secondary prophylaxis and (5) home treatment of patients with low risk pulmonary embolism. This article summarizes the current guidelines for therapy and secondary prophylaxis of pulmonary embolism and novel clinical studies and the possible implications for therapy and secondary prophylaxis of pulmonary embolism.

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Literatur

  1. Kucher N, Rossi E, De Rosa M, Goldhaber SZ (2006) Massive pulmonary embolism. Circulation 113:577–582

    Article  PubMed  Google Scholar 

  2. Wood KE (2002) The presence of shock defines the threshold to initiate thrombolytic therapy in patients with pulmonary embolism. Intensive Care Med 28:1537–1546

    Article  PubMed  Google Scholar 

  3. Kasper W, Konstantinides S, Geibel A et al (1997) Management strategies and determinants of outcome in acute major pulmonary embolism: results of a multicenter registry. J Am Coll Cardiol 30:1165–1171

    Article  PubMed  CAS  Google Scholar 

  4. Grifoni S, Olivotto I, Cecchini P et al (2000) Short-term clinical outcome of patients with acute pulmonary embolism, normal blood pressure, and echocardiographic right ventricular dysfunction. Circulation 101:2817–2822

    Article  PubMed  CAS  Google Scholar 

  5. Kasper W, Konstantinides S, Geibel A et al (1997) Prognostic significance of right ventricular afterload stress detected by echocardiography in patients with clinically suspected pulmonary embolism. Heart 77:346–349

    PubMed  CAS  Google Scholar 

  6. Ribeiro A, Lindmarker P, Juhlin-Dannfelt A et al (1997) Echocardiography Doppler in pulmonary embolism: right ventricular dysfunction as a predictor of mortality rate. Am Heart J 134:479–487

    Article  PubMed  CAS  Google Scholar 

  7. Torbicki A, Perrier A, Konstantinides SV et al (2008) Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). Eur Heart J 29:2276–2315

    Article  PubMed  CAS  Google Scholar 

  8. Jaff MR, McMurtry MS, Archer SL et al (2011) Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. Circulation 123:1788–1830

    Article  PubMed  Google Scholar 

  9. Hach-Wunderle V (2010) Interdisziplinäre S2-Leitlinie: Diagnostik und Therapie der Bein- und Beckenvenenthrombose und der Lungenembolie. Vasa 39:1–39

    Article  Google Scholar 

  10. Wells PS, Anderson DR, Rodger M et al (2001) Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and d-dimer. Ann Intern Med 135:98–107

    Article  PubMed  CAS  Google Scholar 

  11. Le Gal G, Righini M, Roy PM et al (2006) Prediction of pulmonary embolism in the emergency department: the revised Geneva score. Ann Intern Med 144:165–171

    Article  Google Scholar 

  12. Stein PD, Chenevert TL, Fowler SE et al (2010) Gadolinium-enhanced magnetic resonance angiography for pulmonary embolism: a multicenter prospective study (PIOPED III). Ann Intern Med 152:434–443

    Article  PubMed  Google Scholar 

  13. Konstantinides S, Goldhaber SZ (2012) Pulmonary embolism: risk assessment and management. Eur Heart J 33(24):3014–3022

    Article  PubMed  CAS  Google Scholar 

  14. Meneveau N, Seronde MF, Blonde MC et al (2006) Management of unsuccessful thrombolysis in acute massive pulmonary embolism. Chest 129:1043–1050

    Article  PubMed  Google Scholar 

  15. Stein PD, Matta F (2012) Thrombolytic therapy in unstable patients with acute pulmonary embolism: saves lives but underused. Am J Med 125:465–470

    Article  PubMed  Google Scholar 

  16. Stein PD, Matta F, Steinberger DS, Keyes DC (2012) Intracerebral hemorrhage with thrombolytic therapy for acute pulmonary embolism. Am J Med 125:50–56

    Article  PubMed  Google Scholar 

  17. Hach-Wunderle V (2005) Interdisziplinäre S2-Leitlinie: Diagnostik und Therapie der Bein- und Beckenvenenthrombose und der Lungenembolie. Vasa 34(Suppl 66):1–24

    Article  Google Scholar 

  18. Sharifi M, Bay C, Skrocki L et al (2012) Moderate pulmonary embolism treated with thrombolysis (from the „MOPETT“ Trial). Am J Cardiol 111:273–277

    Article  PubMed  Google Scholar 

  19. The PEITHO Steering Committee (2012) Single-bolus tenecteplase plus heparin compared with heparin alone for normotensive patients with acute pulmonary embolism who have evidence of right ventricular dysfunction and myocardial injury: rationale and design of the Pulmonary Embolism Thrombolysis (PEITHO) trial. Am Heart J 163:33–38

    Article  Google Scholar 

  20. Kuo WT, Gould MK, Louie JD et al (2009) Catheter-directed therapy for the treatment of massive pulmonary embolism: systematic review and meta-analysis of modern techniques. J Vasc Interv Radiol 20:1431–1440

    Article  PubMed  Google Scholar 

  21. Prandoni P, Noventa F, Ghirarduzzi A et al (2007) The risk of recurrent venous thromboembolism after discontinuing anticoagulation in patients with acute proximal deep vein thrombosis or pulmonary embolism. A prospective cohort study in 1,626 patients. Haematologica 92:199–205

    Article  PubMed  Google Scholar 

  22. Kearon C, Akl EA, Comerota AJ et al (2012) Antithrombotic therapy for VTE disease: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 141:e419S-e494S

    Article  PubMed  CAS  Google Scholar 

  23. Carrier M, Le GG, Wells PS, Rodger MA (2010) Systematic review: case-fatality rates of recurrent venous thromboembolism and major bleeding events among patients treated for venous thromboembolism. Ann Intern Med 152:578–589

    Article  PubMed  Google Scholar 

  24. Stein PD, Matta F, Keyes DC, Willyerd GL (2012) Impact of vena cava filters on in-hospital case fatality rate from pulmonary embolism. Am J Med 125:478–484

    Article  PubMed  Google Scholar 

  25. Kearon C, Gent M, Hirsh J et al (1999) A comparison of three months of anticoagulation with extended anticoagulation for a first episode of idiopathic venous thromboembolism. N Engl J Med 340:901–907

    Article  PubMed  CAS  Google Scholar 

  26. Budnitz DS, Lovegrove MC, Shehab N, Richards CL (2011) Emergency hospitalizations for adverse drug events in older Americans. N Engl J Med 365:2002–2012

    Article  PubMed  CAS  Google Scholar 

  27. Hylek EM, Evans-Molina C, Shea C et al (2007) Major hemorrhage and tolerability of warfarin in the first year of therapy among elderly patients with atrial fibrillation. Circulation 115:2689–2696

    Article  PubMed  CAS  Google Scholar 

  28. Heneghan C, Ward A, Perera R et al (2012) Self-monitoring of oral anticoagulation: systematic review and meta-analysis of individual patient data. Lancet 379:322–334

    Article  PubMed  Google Scholar 

  29. Witt DM, Sadler MA, Shanahan RL et al (2005) Effect of a centralized clinical pharmacy anticoagulation service on the outcomes of anticoagulation therapy. Chest 127:1515–1522

    Article  PubMed  Google Scholar 

  30. Eichinger S, Heinze G, Jandeck LM, Kyrle PA (2010) Risk assessment of recurrence in patients with unprovoked deep vein thrombosis or pulmonary embolism: the Vienna prediction model. Circulation 121:1630–1636

    Article  PubMed  Google Scholar 

  31. Hull RD, Pineo GF, Brant RF et al (2006) Long-term low-molecular-weight heparin versus usual care in proximal-vein thrombosis patients with cancer. Am J Med 119:1062–1072

    Article  PubMed  CAS  Google Scholar 

  32. Koscielny J, Beyer-Westendorf J, von Heymann C et al (2012) Risk of bleeding and haemorrhagic complication with rivaroxaban – periprocedural management of haemostasis. Hämostaseologie 32:287–293

    Article  PubMed  CAS  Google Scholar 

  33. Spannagl M, Bauersachs R, Debus ES et al (2012) Dabigatran therapy – perioperative management and interpretation of coagulation tests. Hämostaseologie 32:294–305

    Article  PubMed  CAS  Google Scholar 

  34. Schulman S, Kearon C, Kakkar AK et al (2009) Dabigatran versus warfarin in the treatment of acute venous thromboembolism. N Engl J Med 361:2342–2352

    Article  PubMed  CAS  Google Scholar 

  35. Schulman S, Kearon C, Kakkar AK et al (2013) Extended use of dabigatran, warfarin, or placebo in venous thromboembolism. N Engl J Med 368:709–718

    Article  PubMed  CAS  Google Scholar 

  36. The Hokusai-VTE investigators (2013) Edoxaban versus warfarin for the treatment of symptomatic venous thromboembolism. N Engl J Med [Epub ahead of print]

  37. Buller HR, Prins MH, Lensin AW et al (2012) Oral rivaroxaban for the treatment of symptomatic pulmonary embolism. N Engl J Med 366:1287–1297

    Article  PubMed  Google Scholar 

  38. Bauersachs R, Berkowitz SD, Brenner B et al (2010) Oral rivaroxaban for symptomatic venous thromboembolism. N Engl J Med 363:2499–2510

    Article  PubMed  CAS  Google Scholar 

  39. Agnelli G, Buller HR, Cohen A et al; AMPLIFY Investigators (2013) Oral apixaban for the treatment of acute venous thromboembolism. N Engl J Med 369:799–808

    Article  PubMed  CAS  Google Scholar 

  40. Agnelli G, Buller HR, Cohen A et al (2012) Apixaban for extended treatment of venous thromboembolism. N Engl J Med 368:699–708

    Article  PubMed  Google Scholar 

  41. Becattini C, Agnelli G, Schenone A et al (2012) Aspirin for preventing the recurrence of venous thromboembolism. N Engl J Med 366:1959–1967

    Article  PubMed  CAS  Google Scholar 

  42. Brighton TA, Eikelboom JW, Mann K et al (2012) Low-dose aspirin for preventing recurrent venous thromboembolism. N Engl J Med 367:1979–1987

    Article  PubMed  CAS  Google Scholar 

  43. Aujesky D, Obrosky DS, Stone RA et al (2005) Derivation and validation of a prognostic model for pulmonary embolism. Am J Respir Crit Care Med 172:1041–1046

    Article  PubMed  Google Scholar 

  44. Jimenez D, Aujesky D, Moores L et al (2010) Simplification of the pulmonary embolism severity index for prognostication in patients with acute symptomatic pulmonary embolism. Arch Intern Med 170:1383–1389

    Article  PubMed  Google Scholar 

  45. Lankeit M, Jimenez D, Kostrubiec M et al (2011) Predictive value of the high-sensitivity troponin T assay and the simplified pulmonary embolism severity index in hemodynamically stable patients with acute pulmonary embolism: a prospective validation study. Circulation 124:2716–2724

    Article  PubMed  CAS  Google Scholar 

  46. Lankeit M, Friesen D, Aschoff J et al (2010) Highly sensitive troponin T assay in normotensive patients with acute pulmonary embolism. Eur Heart J 31:1836–1844

    Article  PubMed  CAS  Google Scholar 

  47. Squizzato A, Galli M, Dentali F, Ageno W (2009) Outpatient treatment and early discharge of symptomatic pulmonary embolism: a systematic review. Eur Respir J 33:1148–1155

    Article  PubMed  CAS  Google Scholar 

  48. Aujesky D, Roy PM, Verschuren F et al (2011) Outpatient versus inpatient treatment for patients with acute pulmonary embolism: an international, open-label, randomised, non-inferiority trial. Lancet 378:41–48

    Article  PubMed  Google Scholar 

  49. Zondag W, Mos IC, Creemers-Schild D et al (2011) Outpatient treatment in patients with acute pulmonary embolism: the Hestia Study. J Thromb Haemost 9:1500–1507

    Article  PubMed  CAS  Google Scholar 

  50. Agterof MJ, Schutgens RE, Snijder RJ et al (2010) Out of hospital treatment of acute pulmonary embolism in patients with a low NT-proBNP level. J Thromb Haemost 8:1235–1241

    Article  PubMed  CAS  Google Scholar 

  51. Otero R, Uresandi F, Jimenez D et al (2010) Home treatment in pulmonary embolism. Thromb Res 126:e1–e5

    Article  PubMed  CAS  Google Scholar 

  52. Zondag W, Kooiman J, Klok F et al (2012) Outpatient versus inpatient treatment in patients with pulmonary embolism: a meta-analysis. Eur Respir J 42:134–44

    Article  PubMed  Google Scholar 

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Einhaltung ethischer Richtlinien

Interessenkonflikt. S. Konstantinides erhält Vortrags-/Beraterhonorare von Bayer Vital, Boehringer Ingelheim, Bristol-Myers Squibb-Pfizer und Daiichi Sankyo. M. Lankeit erhält Vortrags-/Beraterhonorare von Pfizer Pharma GmbH und Bayer Vital. Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.

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  1. Centrum für Thrombose und Hämostase (CTH), Universitätsmedizin der Johannes Gutenberg-Universität Mainz , Langenbeckstr. 1, 55131, Mainz, Deutschland

    M. Lankeit & S. Konstantinides

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  1. M. Lankeit
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  2. S. Konstantinides
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Correspondence to M. Lankeit.

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Dieser aktualisierte Beitrag erschien ursprünglich in der Zeitschrift Der Kardiologe 2013, 7:217–230. DOI 10.1007/s12181-013-0481-8. Die Teilnahme an der zertifizierten Fortbildung ist nur einmal möglich.

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Lankeit, M., Konstantinides, S. Aktuelle Therapie und Sekundärprävention der Lungenembolie. Pneumologe 10, 443–456 (2013). https://doi.org/10.1007/s10405-013-0744-x

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