Zusammenfassung
Die akute Lungenembolie stellt eine Herausforderung bezüglich einer schnellen Diagnostik und risikoadaptierten Therapie dar. In den 2014 veröffentlichten Leitlinien der Europäischen Gesellschaft für Kardiologie (ESC) zur Diagnose und zum Management der akuten Lungenembolie gibt es einige neue Empfehlungen, basierend auf neuen Studiendaten. Hierzu zählen die Weiterentwicklung von Risiko-Scores sowie der Einsatz eines altersadaptierten D-Dimer-Grenzwertes. Zur Risikoabwägung bei Patienten ohne Schocksymptomatik empfiehlt sich die Anwendung des PESI- bzw. sPESI-Scores, bei intermediärem Risiko kann mit Hilfe der Computertomographie (CT)-Diagnostik oder der Echokardiographie der rechte Ventrikel schnell beurteilt werden sowie mittels laborchemischer Parameter eine weitere Risikostratifizierung erfolgen. Unterdessen haben die neuen oralen Antikoagulanzien (NOAK) Eingang in die Therapieempfehlungen der akuten venösen Thromboembolie und der Rezidivprophylaxe gefunden und sich als gute und sichere Alternative zur Standardtherapie mittels Heparin und Vitamin-K-Antagonisten herausgestellt. Die systemische thrombolytische Therapie sollte weiterhin aufgrund der möglichen Komplikationen in der Gruppe mit intermediär-hohem Risiko nur bei hämodynamischer Verschlechterung erwogen werden. Auf die Diagnostik und Therapie der Lungenembolie bei bestimmten Patientenpopulationen (insbesondere chronisch thromboembolische pulmonale Hypertonie, Patienten mit Malignomen oder Lungenembolie während der Schwangerschaft) wird in der aktuellen Leitlinie ebenso eingegangen.
Abstract
Acute pulmonary embolism (PE) still represents a challenge regarding a rapid diagnosis and a risk-adapted therapy. In the 2014 guidelines of the European Society of Cardiology (ESC) on the diagnosis and management of acute PE, several new recommendations have been issued based on new study data. Some established scores for risk stratification were developed further and there is now good evidence for the use of age-adjusted D-dimer cut-off levels. For the risk stratification in patients without clinical features of shock, the utilization of the pulmonary embolism severity index (PESI) and simplified PESI (sPESI) scores is recommended. In patients with intermediate risk, right ventricular morphology and function can be evaluated by computer tomography or echocardiography and biomarkers facilitate further risk stratification. For the treatment of patients with venous thromboembolism with or without PE, the non-vitamin K-dependent oral anticoagulants (NOACs) are a safe alternative to the standard anticoagulation regimen with heparin and vitamin K antagonists. Systemic thrombolytic therapy should be restricted to patients with high risk or intermediate high risk with hemodynamic instability. Finally, new recommendations for the diagnosis and therapy of patients with chronic thromboembolic pulmonary hypertension (CTEPH), with cancer or during pregnancy are given.
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J.A. Saar gibt an, dass kein Interessenkonflikt besteht. C. Maack erhielt Vortragshonorare von Bayer, Pfizer, Bristol-Myers-Squibb und Boehringer Ingelheim.
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Saar, J., Maack, C. Diagnose und Management der akuten pulmonalen Embolie. Herz 40, 1048–1054 (2015). https://doi.org/10.1007/s00059-015-4378-0
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DOI: https://doi.org/10.1007/s00059-015-4378-0
Schlüsselwörter
- Venöse Thromboembolie
- Leitlinien
- Neue orale Antikoagulanzien
- Chronische thromboembolische pulmonale Hypertonie
- PESI