Risikoadaptiertes Management der Lungenembolie

Abstract

Acute pulmonary embolism represents one of the two clinical manifestations of venous thromboembolism and constitutes the third most frequent acute cardiovascular disease with increasing incidence in the ageing population. In the past years, significant progress was made in diagnostic modalities and risk stratification tools as well as in the treatment (i. e. anticoagulation and reperfusion) options. The recently updated pulmonary embolism guidelines of the European Society of Cardiology offer an integrated risk-adjusted approach to pulmonary embolism and may help to optimize treatment and prognosis of the disease, both in the acute phase and over the long term.

Kernaussagen

• Bereits beim klinischen Verdacht auf eine akute Lungenembolie ist die Initiierung der Antikoagulation indiziert.

• Die Therapie der akuten LE richtet sich nach der Einschätzung des Mortalitätsrisikos. Als erster Schritt des Management-Algorithmus wird das Vorhandensein eines Schocks bzw. einer persistierenden arteriellen Hypotonie beurteilt.

• Die Hochrisiko-LE (Schock oder persistierende Hypotonie bei Aufnahme) erfordert eine sofortige Reperfusionstherapie mittels Fibrinolyse oder – im Fall von Kontraindikationen oder Therapieversagen – eine operative bzw. kathetergestützte Thrombusentfernung.

• Die Nicht-Hochrisiko-LE (kein Schock oder Hypotonie) wird durch klinische Parameter sowie bildgebende und laborchemische Untersuchungen weiter unterteilt und entsprechend der Risikoeinschätzung stationär mit Überwachung oder ggf. ambulant behandelt.

• Die Fortsetzung der Antikoagulation über die ersten 3 Monate hinaus ist abhängig von den begleitenden Risikofaktoren für ein thromboembolisches Rezidiv.

• Literatur

• 1 Cohen AT, Agnelli G, Anderson FA et al. Venous thromboembolism (VTE) in Europe. The number of VTE events and associated morbidity and mortality. Thromb Haemost 2007; 98: 756-764
• 2 Konstantinides SV, Torbicki A, Agnelli G et al. 2014 ESC 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) Endorsed by the European Respiratory Society (ERS). Eur Heart J 2014; 35: 3033-3073
• 3 Konstantinides S, Goldhaber SZ. Pulmonary embolism: risk assessment and management. Eur Heart J 2012; 33: 3014-3022
• 4 Aujesky D, Obrosky DS, Stone RA et al. Derivation and validation of a prognostic model for pulmonary embolism. Am J Respir Crit Care Med 2005; 172: 1041-1046
• 5 Jimenez D, Aujesky D, Moores L et al. Simplification of the pulmonary embolism severity index for prognostication in patients with acute symptomatic pulmonary embolism. Arch Intern Med 2010; 170: 1383-1389
• 6 Becattini C, Agnelli G, Germini F et al. Computed tomography to assess risk of death in acute pulmonary embolism: a meta-analysis. Eur Respir J 2014; 43: 1678-1690
• 7 Lankeit M, Jimenez D, Kostrubiec M et al. Validation of N-terminal pro-brain natriuretic peptide cut-off values for risk stratification of pulmonary embolism. Eur Respir J 2014; 43: 1669-1677
• 8 Meyer G, Vicaut E, Danays T et al. Fibrinolysis for patients with intermediate-risk pulmonary embolism. N Engl J Med 2014; 370: 1402-1411
• 9 Meneveau N, Seronde MF, Blonde MC et al. Management of unsuccessful thrombolysis in acute massive pulmonary embolism. Chest 2006; 129: 1043-1050
• 10 Daniels LB, Parker JA, Patel SR et al. Relation of duration of symptoms with response to thrombolytic therapy in pulmonary embolism. Am J Cardiol 1997; 80: 184-188
• 11 Kline JA, Nordenholz KE, Courtney DM et al. Treatment of submassive pulmonary embolism with tenecteplase or placebo: cardiopulmonary outcomes at 3 months: multicenter double-blind, placebo-controlled randomized trial. J Thromb Haemost 2014; 12: 459-468
• 12 Marti C, John G, Konstantinides S et al. Systemic thrombolytic therapy for acute pulmonary embolism: a systematic review and meta-analysis. Eur Heart J 2015; 36: 605-614
• 13 Chartier L, Bera J, Delomez M et al. Free-floating thrombi in the right heart: diagnosis, management, and prognostic indexes in 38 consecutive patients. Circulation 1999; 99: 2779-2283
• 14 Konstantinides S, Marder VJ. Thrombolysis in venous thromboembolism. In: Colman RW, Marder VJ, Clowes AW, et al. (eds) Hemostasis and Thrombosis. Philadelphia: Lippincott Williams and Wilkins; 2006: 1317-1329
• 15 Myers PO, Bounameaux H, Panos A et al. Impending paradoxical embolism: systematic review of prognostic factors and treatment. Chest 2010; 137: 164-170
• 16 Kuo WT, Gould MK, Louie JD et al. Catheter-directed therapy for the treatment of massive pulmonary embolism: systematic review and meta-analysis of modern techniques. J Vasc Interv Radiol 2009; 20: 1431-1440
• 17 Engelberger RP, Kucher N. Ultrasound-assisted thrombolysis for acute pulmonary embolism: a systematic review. Eur Heart J 2014; 35: 758-764
• 18 Kucher N, Boekstegers P, Muller OJ et al. Randomized, controlled trial of ultrasound-assisted catheter-directed thrombolysis for acute intermediate-risk pulmonary embolism. Circulation 2014; 129: 479-486
• 19 Schulman S, Kearon C, Kakkar AK et al. Dabigatran versus warfarin in the treatment of acute venous thromboembolism. N Engl J Med 2009; 361: 2342-2352
• 20 Schulman S, Kakkar AK, Goldhaber SZ et al. Treatment of acute venous thromboembolism with dabigatran or warfarin and pooled analysis. Circulation 2014; 129: 764-772
• 21 Buller HR, Prins MH, Lensin AW et al. Oral rivaroxaban for the treatment of symptomatic pulmonary embolism. N Engl J Med 2012; 366: 1287-1297
• 22 Bauersachs R, Berkowitz SD, Brenner B et al. Oral rivaroxaban for symptomatic venous thromboembolism. N Engl J Med 2010; 363: 2499-2510
• 23 Agnelli G, Buller HR, Cohen A et al. Oral apixaban for the treatment of acute venous thromboembolism. N Engl J Med 2013; 369: 799-808
• 24 Buller HR, Decousus H, Grosso MA et al. Edoxaban versus warfarin for the treatment of symptomatic venous thromboembolism. N Engl J Med 2013; 369: 1406-1415
• 25 van Es N, Coppens M, Schulman S et al. Direct oral anticoagulants compared with vitamin K antagonists for acute venous thromboembolism: evidence from phase 3 trials. Blood 2014; 124: 1968-1975
• 26 Kearon C, Gent M, Hirsh J et al. A comparison of three months of anticoagulation with extended anticoagulation for a first episode of idiopathic venous thromboembolism [see comments]. N Engl J Med 1999; 340: 901-907 ; erratum in N Engl J Med 1999; 341: 298
• 27 Heit JA. Predicting the risk of venous thromboembolism recurrence. Am J Hematol 2012; 87 (Suppl. 01) S63-S67
• 28 Schulman S, Kearon C, Kakkar AK et al. Extended use of dabigatran, warfarin, or placebo in venous thromboembolism. N Engl J Med 2013; 368: 709-718
• 29 Agnelli G, Buller HR, Cohen A et al. Apixaban for extended treatment of venous thromboembolism. N Engl J Med 2013; 368: 699-708