Ambulante Thrombosebehandlung

Zusammenfassung

Mehrere Studien belegen, dass die subkutane Gabe von niedermolekularem Heparin in der Initialbehandlung der venösen Thrombose mindestens so effektiv und sicher ist wie die intravenöse Gabe von unfraktioniertem Heparin. Damit wird erstmals auch eine ambulante Thrombosebehandlung möglich. Ein leitliniengerechtes Thrombosemanagement erfordert zunächst eine sichere Thrombosediagnostik. Anschließend muss individuell für jeden Patienten die initiale Antikoagulation mit Heparin wie auch die nachfolgende Umstellung auf Vitamin-K-Antagonisten und das erforderliche Monitoring sichergestellt werden. Kontraindikationen und Begleiterkrankungen sind zu berücksichtigen und können zusammen mit der individuellen Behandlungssituation Gründe für eine stationäre Aufnahme darstellen. Eine Checkliste kann zwar bei der Entscheidung helfen, erübrigt aber nicht die Aufklärung und Abwägung der Vor- und Nachteile einer ambulanten Behandlung für jeden Einzelfall.

Summary

There is sound evidence, that low molecular weight heparin (LMWH) administered subcutaneously is at least as effective and safe as an i.v. infusion of unfractionated heparin. Thus, with LMWH out-patient treatment of deep vein thrombosis (DVT) becomes feasible. According to the current guidelines, an objective diagnosis of DVT is required before the anticoagulation with heparin is initiated. Close monitoring is also required during the subsequent initiation of treatment with vitamin K antagonist. Contraindications and comorbid conditions need to be identified and may necessitate hospital treatment. A checklist may assist in the decision for or against out-patient treatment, but an individual assessment for the individual patient is always a requisite.

Schlüsselwörter

Thrombose - Heparin - orale Antikoagulation - ambulante Behandlung

Keywords

Venous thrombosis - out-patient treatment - heparin - anticoagulation

• Literatur

• 1 Aschwanden M, Labs KH, Engel H. et al. Acute deep vein thrombosis: Early mobilization does not increase the frequency of pulmonary embolism. Thromb Haemost 2001; 85: 42-6.
• 2 Bauersachs RM, Lindhoff-Last E, Wolff U. et al. Aktuelles Management der tiefen Venenthrombose. Med Welt 1998; 49: 194-214.
• 3 Brandjes DP, Heijboer H, Büller HR. et al. Acenocoumarol and heparin compared with acenocoumarol alone in the initial treatment of proximal-vein thrombosis. N Engl J Med 1992; 327: 1485-9.
• 4 Brandjes DP, Büller HR, Heijboer H. et al. Randomized trial of effect of compression stockings in patients with symptomatic proximal vein thrombosis. Lancet 1997; 349: 759-62.
• 5 Dolovich LR, Ginsberg JS, Douketis JD. et al. A meta-analysis comparing low-molecular-weight heparins with unfractionated heparin in the treatment of venous thromboembolism: examining some unanswered questions regarding location of treatment, product type, and dosing frequency. Arch Intern Med 2000; 160: 181-8.
• 6 Franzeck UK, Schalch I, Jäger KA. et al. Prospective 12-year follow-up study of clinical and hemodynamic sequelae after deep vein thrombosis in low-risk patients. Circulation 1996; 93: 74-9.
• 7 Ginsberg J. Management of venous thromboembolism. N Engl J Med 1996; 335: 1816-28.
• 8 Hull RD, Raskob GE, Brant RF. et al. The importance of initial heparin treatment on long-term clinical outcomes of antithrombotic therapy. The emerging theme of delayed recurrence. Arch Int Med 1997; 157: 2317-21.
• 9 Koopman MMW, Prandoni P, Piovella F. et al. for the Tasman Study Group. Treatment of venous thrombosis with intravenous unfractionated heparin administered in the hospital as compared with subcutaneous low-molecular-weight heparin administered at home. N Engl J Med 1996; 334: 682-7.
• 10 Kraaijenhagen RA, Lensing AWA, Lijmer JG. et al. Diagnostic strategies for the management of patients with clinically suspected deep vein thrombosis. Curr Opin Pulm Med 1997; 3: 268-74.
• 11 Leitlinien der Deutschen Gesellschaft für Angiologie – Gesellschaft für Gefäßmedizin. Diagnostik und Therapie der Venenthrombose und Lungenembolie. Vasa. 2002 31. (Suppl 60).
• 12 Levine M, Gent M, Hirsh J. et al. A comparison of lowmolecular-weight heparin administered primarily at home with unfractionated heparin administered in the hospital for proximal deep-vein thrombosis. N Engl J Med 1996; 334: 677-81.
• 13 Lopaciuk S, Bielska-Falda H, Noszczyk W. et al. Low molecular weight heparin versus acenocoumarol in the secondary prophylaxis of deep vein thrombosis. Thromb Haemost 1999; 81: 26-31.
• 14 Partsch H. Therapy of deep vein thrombosis with low molecular weight heparin, leg compression and immediate ambulation. Vasa 2001; 30: 195-204.
• 15 Perrier A, Dèsmarais S, Miron MJ. et al. Noninvasive diagnosis of venous thromboembolism in outpatients. Lancet 1999; 353: 190-5.
• 16 Schellong SM, Schwarz T, Kropp J. et al. Bed rest in deep vein thrombosis and the incidence of scintigraphic pulmonary embolism. Thromb Haemost 1999; 82 (Suppl): 127-9.
• 17 Schraibman IG, Milne AA, Royle EM. Home versus in-patient treatment for deep vein thrombosis. Cochrane Database Syst Rev 2001; CD003076.
• 18 Schwarz T, Schmidt B, Hohlein U. et al. Eligibility for home treatment of deep vein thrombosis: prospective study. Brit Med J 2001; 322 (7296): 1212-3.
• 19 Topol EJ, Fuster V, Harrinton RA. et al. Recombinant Hirudin for unstable Angina Pectoris. A multicenter, randomized angiographic Trial. Circulation 1994; 89: 1557-64.
• 20 Wells PS, Anderson DR, Bormanis J. et al. Value of assessment of pretest probability of deep-vein thrombosis in clinical management. Lancet 1997; 350: 1795-8.