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Therapie und Sekundärprophylaxe der venösen Thromboembolie mit Vitamin-K-Antagonisten

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Zusammenfassung

Die orale Antikoagulation mit Vitamin-K-Antagonisten ist eine sehr effektive Maßnahme zur Sekundärprophylaxe der akuten venösen Thromboembolie. Während in Deutschland vor allem Phenprocoumon eingesetzt wird, liegen die meisten evidenzbasierten Daten aus kontrollierten Studien für Warfarin vor. Bei der Therapie einer akuten venösen Thrombembolie erfolgt die Antikoagulation initial mit Heparin, überlappend wird die orale Antikoagulation eingeleitet. In dieser Phase ist die Einstellung oft noch instabil und das Blutungsrisiko erhöht. Der Zielbereich ist eine INR zwischen 2 und 3, bei der eine optimale Effektivität bei geringstem Risiko schwerer Blutungen besteht. Das individuelle Blutungsrisiko lässt sich oft durch anamnestische Angaben abschätzen. Die Antikoagulation wird nach einer ersten Thromboembolie in der Regel 6 Monate durchgeführt, nach Rezidiven mindestens 1–2 Jahre. Diese Zeiten können nach dem individuellen Rezidivrisiko variiert werden. Wegen der zahlreichen praktischen Probleme der Vitamin-K-Antagonisten und des engen therapeutischen Fensters werden neue orale Antithrombotika entwickelt, die in Zukunft die Risikoabwägung zugunsten einer längeren Antikoagulation verschieben könnten.

Abstract

Oral anticoagulation with vitamin-K-antagonists is very effective in secondary prevention of venous thromboembolism. In Germany, most commonly Phenprocoumon is used, while most of the evidence-based data are available for Warfarin. The initial treatment of acute venous thromboembolism requires immediate anticoagulation with heparin and a subsequent overlapping treatment with oral anticoagulants. During this phase, anticoagulation may be unstable with increased risk for bleeding. An INR target range between 2 and 3 provides effective protection with minimal risk for major bleeding. The individual risk for bleeding may be estimated by a clinical score. Six months of oral anticoagulation is the standard duration for a first episode of venous thromboembolism, while recurrencies are treated for at least one to two years. The duration may be tailored to the individual patient according to underlying risk factors for recurrencies and for bleeding. Because of a plethora of practical problems and the narrow therapeutic window, there is a need for new antithrombotic agents. These may allow a longer duration of secondary prevention with improved protection against recurrencies without sacrificing safety.

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  1. Medizinische Klinik IV, Max-Ratschow-Klinik für Angiologie, Städtisches Klinikum Darmstadt

    R. M. Bauersachs

  2. Medizinische Klinik IV, Max-Ratschow-Klinik für Angiologie, Klinikum Darmstadt, Heidelberger Landstraße 379, 64297, Darmstadt

    R. M. Bauersachs

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Bauersachs, R.M. Therapie und Sekundärprophylaxe der venösen Thromboembolie mit Vitamin-K-Antagonisten. Internist 44, 1491–1499 (2003). https://doi.org/10.1007/s00108-003-1081-7

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  • DOI: https://doi.org/10.1007/s00108-003-1081-7

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