Lungenembolie

In diesem Übersichtsartikel werden aktuelle Empfehlungen internationaler Leitlinien sowie die neuesten Erkenntnisse zur Diagnose, Risikostratifizierung, medikamentösen und kathetergestützten Reperfusionsbehandlung sowie der initialen und langfristigen Antikoagulation unter Berücksichtigung des individuellen Rezidiv- und Blutungsrisikos bei Patienten mit Lungenembolie zusammengefasst, durch klinische Fallbeispiele begleitet und kritisch diskutiert.

Abstract

Pulmonary embolism (PE) is a life-threatening disease and the third most frequent cardiovascular cause of death after stroke and myocardial infarction. The annual incidence is increasing (in Germany from 85 cases per 100000 population in the year 2005 to 109 cases per 100000 population in the year 2015). The individual risk for PE-related complications and death increases with the number of comorbidities and severity of right ventricular dysfunction. Using clinical, laboratory and imaging parameters, patients with PE can be stratified to four risk classes (high, intermediate-high, intermediate-low and low risk). This risk stratification has concrete therapeutic consequences ranging from out-of-hospital treatment of low-risk patients to reperfusion treatment of (intermediate)-high-risk patients. For haemodynamically unstable patients, treatment decision should preferably be made in interdisciplinary “Pulmonary Embolism Response Teams” (PERT). Due to their comparable efficacy and preferable safety profile compared to vitamin-K antagonists (VKAs), non-vitamin K-dependent oral anticoagulants (NOACs) are increasingly considered the treatment of choice for initial and prolonged anticoagulation of patients with pulmonary embolism. Use of low molecular weight heparins (LMWHs) is recommended for PE patients with cancer; however, recent studies indicate that treatment with factor Xa-inhibitors may be effective and safe (in patients without gastrointestinal cancer). Only prolonged anticoagulation (in reduced dosage) will ensure reduction of VTE recurrence and should thus be considered for all patients with unprovoked events.

Kernaussagen

• Die akute Lungenembolie stellt nach dem Myokardinfarkt und dem Schlaganfall die dritthäufigste kardiovaskuläre Todesursache dar.

• Die Inzidenz einer Lungenembolie ist steigend (in Deutschlang von 85 pro 100 000 Einwohner im Jahr 2005 auf 109 pro 100 000 Einwohner im Jahr 2015).

• Das individuelle Risiko für mit Lungenembolie assoziierte Komplikationen und Letalität steigt mit der Anzahl von Begleiterkrankungen und dem Ausmaß der rechtsventrikulären Dysfunktion.

• Mittels klinischer, laborchemischer und bildgebender Parameter können Patienten mit Lungenembolie in 4 Risikoklassen eingeteilt werden (hoch, intermediär-hoch, intermediär-niedrig, niedrig).

• Die Therapie von Patienten mit Lungenembolie richtet sich nach dem individuellen Risikoprofil und reicht von einer ambulanten Behandlung bis hin zur rekanalisierenden Therapie mit intensivmedizinischem Monitoring.

• Zur ambulanten Therapie wird eine orale Antikoagulation mit einem NOAK (Apixaban, Dabigatran, Edoxaban oder Rivaroxaban) empfohlen und den Vitamin K-Antagonisten vorgezogen.

• Therapieentscheidungen für hämodynamisch instabile Lungenemboliepatienten sollten im interdisziplinären Expertenteam (Pulmonary Embolism Response Team [PERT]) getroffen werden.

• Für Lungenemboliepatienten mit Krebserkrankung kann eine therapeutische Antikoagulation mit NMH (mindestens 3–6 Monate) durchgeführt werden, aber auch die Anwendung von Faktor Xa-Inhibitoren ist bei Krebspatienten (ohne gastrointestinale Tumoren) effektiv und sicher.

• Für die Sekundärprophylaxe von Lungenembolien und venösen Thromboembolie (VTE) ist es entscheidend, ob ein niedriges oder eine hohes Rezidivrisiko vorliegt. Ein wirksamer Schutz vor einem VTE-Rezidiv ist nur durch eine Fortführung der Antikoagulation (auf unbestimmte Dauer) gegeben und sollte für alle Patienten mit einem hohen Rezidivrisiko (Antiphospholipid-Syndrom, Krebserkrankung, VTE in der Anamnese) erwogen werden.

Schlüsselwörter

Lungenembolie - Risikostratifizierung - Thrombolyse - Antikoagulation - Dyspnoe

Keywords

pulmonary embolism - risk stratification - thrombolysis - anticoagulation

Publication History

Article published online:
18 October 2021

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