Abstract
The present article addresses clinical challenges associated with the choice of the
anticoagulant agent, the definition of the duration of anticoagulant treatment and
the assessment of the risk-to-benefit ratio of prolonged anticoagulation for patients
with pulmonary embolism (PE).
Anticoagulation is performed with unfractionated heparin (UFH) in hemodynamically
unstable patients and with low molecular weight heparins (LWMH) or fondaparinux in
normotensive patients. In patients with high or intermediate clinical probability
of pulmonary embolism, anticoagulation should be initiated without delay while awaiting
the results of diagnostic tests. LMWH and fondaparinux are preferred over UFH in the
initial anticoagulation of PE since they are associated with a lower risk of bleeding.
All patients with PE require therapeutic anticoagulation for at least three months.
The current 2019 guidelines of the European Society of Cardiology (ESC) recommend
that all eligible patients should be treated with a non-vitamin K antagonist oral
anticoagulant (NOAC) in preference to a vitamin K antagonist (VKA). In patients with
active cancer, Apixaban, Edoxaban and Rivaroxaban are effective alternatives to treatment
with LMWH.
The decision on the duration of anticoagulation should consider both, the individual
risk of PE recurrence and the individual risk of bleeding. The risk for recurrent
PE after discontinuation of treatment is related to the features of the index PE event.
While patients with a strong transient risk factor have a low risk of recurrence and
anticoagulation can be discontinued after three months, patients with strong persistent
risk factor (such as active cancer) have a high risk of recurrence and thus should
receive anticoagulant treatment of indefinite duration. Given the favourable safety
profile of NOACs (especially if a reduced dosage of Apixaban or Rivaroxaban is initiated
after at least six months of therapeutic anticoagulation), extended oral anticoagulation
of indefinite duration should be considered for all patients with intermediate risk
of recurrence.
Alle Patienten mit Lungenembolie benötigen eine therapeutische Antikoagulation für mindestens
3 Monate. Dieser Beitrag behandelt klinische Herausforderungen der Therapie: die Wahl
des geeigneten Antikoagulanz, das Festlegen der Antikoagulationsdauer und die Abschätzung
des Nutzen-Risiko-Verhältnisses. Besonders berücksichtigt werden dabei die Empfehlungen
der kürzlich publizierten 2019-Leitlinie der European Society of Cardiology.
Schlüsselwörter
Lungenembolie - Antikoagulation - Nicht-Vitamin-K-abhängige orale Antikoagulanzien
(NOAK) - Risikoabschätzung - Blutungsrisiko
Key words
pulmonary embolism - anticoagulation - non-vitamin K antagonist oral anticoagulants
- risk assessment - bleeding risk
