Zusammenfassung
Die wesentlichen Behandlungsziele bei venöser Thromboembolie sind die Vermeidung einer Thrombusprogression bzw. einer Lungenembolie, die Senkung der Mortalität, die Vermeidung eines thromboembolischen Rezidivs und die Sekundärprävention postthrombotischer Folgeerkrankungen. Wichtigste Maßnahme ist die frühzeitige und effektive Antikoagulation mit Heparin, wobei derzeit als Mittel der Wahl niedermolekulare Heparine (NMH) oder alternativ Fondaparinux anzusehen sind. Eine Behandlung mit unfraktioniertem Heparin (UFH) ist ebenso effektiv, bedarf allerdings eines Gerinnungsmonitorings. Darüber hinaus ist das Risiko einer heparininduzierten Thrombozytopenie höher als unter NMH. Bei Niereninsuffizienz sind aufgrund der Kumulationsgefahr unter NMH eine Bestimmung der Anti-Xa-Aktivität, ggf. Dosisanpassungen oder die Behandlung mit UFH geboten. Die weitere Antikoagulation erfolgt in der Regel mit Vitamin-K-Antagonisten (INR-Zielbereich 2–3) für 3–6 Monate, bei rezidivierender Thromboembolie längerfristig. Darüber hinaus ist eine Kompressionsbehandlung sinnvoll. Wenn ansonsten keine schwerwiegenden Erkrankungen bestehen, die eine stationäre Behandlung erfordern, und das Blutungsrisiko nicht erhöht ist, können Patienten, die keine massive venöse Stauungssymptomatik oder eine symptomatische Lungenembolie aufweisen, ambulant behandelt werden. Bettruhe ist meist nicht erforderlich. Thrombusbeseitigende Verfahren sind nur in schwerwiegenden Ausnahmefällen indiziert.
Abstract
The main objectives in the treatment of venous thromboembolism are to prevent clot extension and pulmonary embolism, to reduce mortality and to prevent recurrent thromboembolic events as well as postthrombotic disorders. Initial and effective anticoagulation with heparin, preferably with low molecular weight heparin (LMWH), or with fondaparinux is the most important measure. Unfractioned heparin (UFH) is as effective as LMWH, but requires coagulation-monitoring and is associated with a higher risk of heparin-induced thrombocytopenia. In patients with renal insufficiency direct determination of anti-factor Xa activity and dose adjustment is recommended, since drug accumulation can occur over time. In those patients UFH instead of LMWH might be favored. Long-term treatment should be administered with vitamin K-antagonists (INR-target range 2–3) for a duration of 3 to 6 months. In case of recurrent venous thromboembolism, indefinite therapy is recommended. Additional treatment with compression stockings is reasonable. Patients who do not require hospital treatment for other conditions, who have a low bleeding risk, no excessive venous congestion and no symptomatic pulmonary embolism can safely be treated at home. In most cases bed rest is not necessary. Thrombolysis or surgical thrombectomy is seldomly indicated in severe thromboembolism.
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Willeke, A., Lindhoff-Last, E. Therapie der venösen Thromboembolie. Internist 51, 335–343 (2010). https://doi.org/10.1007/s00108-009-2514-8
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DOI: https://doi.org/10.1007/s00108-009-2514-8