Gefässchirurgie

, Volume 19, Issue 1, pp 77–90

Aktuelle Therapie und Sekundärprävention der Lungenembolie

CME Zertifizierte Fortbildung
  • 301 Downloads

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.

Schlüsselwörter

Risikostratifizierung Thrombolyse Neue orale Antikoagulanzien Azetylsalizylsäure Ambulante Behandlung 

Current therapy and secondary prophylaxis of pulmonary embolism

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.

Keywords

Risk stratification Thrombolysis Novel oral anticoagulants Acetylsalicylic acid Home treatment 

Literatur

  1. 1.
    Kucher N, Rossi E, De Rosa M, Goldhaber SZ (2006) Massive pulmonary embolism. Circulation 113:577–582PubMedCrossRefGoogle Scholar
  2. 2.
    Wood KE (2002) The presence of shock defines the threshold to initiate thrombolytic therapy in patients with pulmonary embolism. Intensive Care Med 28:1537–1546PubMedCrossRefGoogle Scholar
  3. 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 30:1165–1171PubMedCrossRefGoogle Scholar
  4. 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 101:2817–2822PubMedCrossRefGoogle Scholar
  5. 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 77:346–349PubMedCentralPubMedGoogle Scholar
  6. 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 134:479–487PubMedCrossRefGoogle Scholar
  7. 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 29:2276–2315PubMedCrossRefGoogle Scholar
  8. 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 123:1788–1830PubMedCrossRefGoogle Scholar
  9. 9.
    Hach-Wunderle V (2010) Interdisziplinäre S2-Leitlinie: Diagnostik und Therapie der Bein- und Beckenvenenthrombose und der Lungenembolie. Vasa 39:1–39CrossRefGoogle Scholar
  10. 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 135:98–107PubMedCrossRefGoogle Scholar
  11. 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 144:165–171CrossRefGoogle Scholar
  12. 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 152:434–443PubMedCentralPubMedCrossRefGoogle Scholar
  13. 13.
    Konstantinides S, Goldhaber SZ (2012) Pulmonary embolism: risk assessment and management. Eur Heart J 33(24):3014–3022PubMedCrossRefGoogle Scholar
  14. 14.
    Meneveau N, Seronde MF, Blonde MC et al (2006) Management of unsuccessful thrombolysis in acute massive pulmonary embolism. Chest 129:1043–1050PubMedCrossRefGoogle Scholar
  15. 15.
    Stein PD, Matta F (2012) Thrombolytic therapy in unstable patients with acute pulmonary embolism: saves lives but underused. Am J Med 125:465–470PubMedCrossRefGoogle Scholar
  16. 16.
    Stein PD, Matta F, Steinberger DS, Keyes DC (2012) Intracerebral hemorrhage with thrombolytic therapy for acute pulmonary embolism. Am J Med 125:50–56PubMedCrossRefGoogle Scholar
  17. 17.
    Hach-Wunderle V (2005) Interdisziplinäre S2-Leitlinie: Diagnostik und Therapie der Bein- und Beckenvenenthrombose und der Lungenembolie. Vasa 34(Suppl 66):1–24CrossRefGoogle Scholar
  18. 18.
    Sharifi M, Bay C, Skrocki L et al (2012) Moderate pulmonary embolism treated with thrombolysis (from the „MOPETT“ Trial). Am J Cardiol 111:273–277PubMedCrossRefGoogle Scholar
  19. 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 163:33–38CrossRefGoogle Scholar
  20. 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 20:1431–1440PubMedCrossRefGoogle Scholar
  21. 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 92:199–205PubMedCrossRefGoogle Scholar
  22. 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-e494SPubMedCentralPubMedCrossRefGoogle Scholar
  23. 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 152:578–589PubMedCrossRefGoogle Scholar
  24. 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 125:478–484PubMedCrossRefGoogle Scholar
  25. 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 340:901–907PubMedCrossRefGoogle Scholar
  26. 26.
    Budnitz DS, Lovegrove MC, Shehab N, Richards CL (2011) Emergency hospitalizations for adverse drug events in older Americans. N Engl J Med 365:2002–2012PubMedCrossRefGoogle Scholar
  27. 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 115:2689–2696PubMedCrossRefGoogle Scholar
  28. 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 379:322–334PubMedCrossRefGoogle Scholar
  29. 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 127:1515–1522PubMedCrossRefGoogle Scholar
  30. 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 121:1630–1636PubMedCrossRefGoogle Scholar
  31. 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 119:1062–1072PubMedCrossRefGoogle Scholar
  32. 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 32:287–293PubMedCrossRefGoogle Scholar
  33. 33.
    Spannagl M, Bauersachs R, Debus ES et al (2012) Dabigatran therapy – perioperative management and interpretation of coagulation tests. Hämostaseologie 32:294–305PubMedCrossRefGoogle Scholar
  34. 34.
    Schulman S, Kearon C, Kakkar AK et al (2009) Dabigatran versus warfarin in the treatment of acute venous thromboembolism. N Engl J Med 361:2342–2352PubMedCrossRefGoogle Scholar
  35. 35.
    Schulman S, Kearon C, Kakkar AK et al (2013) Extended use of dabigatran, warfarin, or placebo in venous thromboembolism. N Engl J Med 368:709–718PubMedCrossRefGoogle Scholar
  36. 36.
    The Hokusai-VTE investigators (2013) Edoxaban versus warfarin for the treatment of symptomatic venous thromboembolism. N Engl J Med [Epub ahead of print]Google Scholar
  37. 37.
    Buller HR, Prins MH, Lensin AW et al (2012) Oral rivaroxaban for the treatment of symptomatic pulmonary embolism. N Engl J Med 366:1287–1297PubMedCrossRefGoogle Scholar
  38. 38.
    Bauersachs R, Berkowitz SD, Brenner B et al (2010) Oral rivaroxaban for symptomatic venous thromboembolism. N Engl J Med 363:2499–2510PubMedCrossRefGoogle Scholar
  39. 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 369:799–808PubMedCrossRefGoogle Scholar
  40. 40.
    Agnelli G, Buller HR, Cohen A et al (2012) Apixaban for extended treatment of venous thromboembolism. N Engl J Med 368:699–708PubMedCrossRefGoogle Scholar
  41. 41.
    Becattini C, Agnelli G, Schenone A et al (2012) Aspirin for preventing the recurrence of venous thromboembolism. N Engl J Med 366:1959–1967PubMedCrossRefGoogle Scholar
  42. 42.
    Brighton TA, Eikelboom JW, Mann K et al (2012) Low-dose aspirin for preventing recurrent venous thromboembolism. N Engl J Med 367:1979–1987PubMedCrossRefGoogle Scholar
  43. 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 172:1041–1046PubMedCentralPubMedCrossRefGoogle Scholar
  44. 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 170:1383–1389PubMedCrossRefGoogle Scholar
  45. 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 124:2716–2724PubMedCrossRefGoogle Scholar
  46. 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 31:1836–1844PubMedCrossRefGoogle Scholar
  47. 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 33:1148–1155PubMedCrossRefGoogle Scholar
  48. 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 378:41–48PubMedCrossRefGoogle Scholar
  49. 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 9:1500–1507PubMedCrossRefGoogle Scholar
  50. 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 8:1235–1241PubMedCrossRefGoogle Scholar
  51. 51.
    Otero R, Uresandi F, Jimenez D et al (2010) Home treatment in pulmonary embolism. Thromb Res 126:e1–e5PubMedCrossRefGoogle Scholar
  52. 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 42:134–44PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2014

Authors and Affiliations

  1. 1.Centrum für Thrombose und Hämostase (CTH)Universitätsmedizin der Johannes-Gutenberg-Universität MainzMainzDeutschland

Personalised recommendations