Skip to main content
SpringerLink
Log in

Diagnose und Management der akuten pulmonalen Embolie

ESC-Leitlinien 2014

Diagnosis and management of acute pulmonary embolism

ESC guidelines 2014

  • Schwerpunkt
  • Published:
Herz Aims and scope Submit manuscript

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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Abb. 1

Literatur

  1. Konstantinides SV, Torbicki A, Agnelli G, Danchin N et al (2014) 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J 35:3033–3069, 3069a–3069k

    Article  PubMed  Google Scholar 

  2. Anderson FA Jr, Spencer FA (2003) Risk factors for venous thromboembolism. Circulation 107:I9–I16

    Article  PubMed  Google Scholar 

  3. Pollack CV, Schreiber D, Goldhaber SZ, Slattery D et al (2011) Clinical characteristics, management, and outcomes of patients diagnosed with acute pulmonary embolism in the emergency department: initial report of EMPEROR (Multicenter Emergency Medicine Pulmonary Embolism in the Real World Registry). J Am Coll Cardiol 57:700–706

    Article  PubMed  Google Scholar 

  4. Wells PS, Anderson DR, Rodger M, Ginsberg JS et al (2000) Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED D-dimer. Thromb Haemost 83:416–420

    CAS  PubMed  Google Scholar 

  5. Douma RA, Mos IC, Erkens PM, Nizet TA et al (2011) Performance of 4 clinical decision rules in the diagnostic management of acute pulmonary embolism: a prospective cohort study. Ann Intern Med 154:709–718

    Article  PubMed  Google Scholar 

  6. Righini M, Goehring C, Bounameaux H, Perrier A (2000) Effects of age on the performance of common diagnostic tests for pulmonary embolism. Am J Med 109:357–361

    Article  CAS  PubMed  Google Scholar 

  7. Schouten HJ, Geersing GJ, Koek HL, Zuithoff NP et al (2013) Diagnostic accuracy of conventional or age adjusted D-dimer cut-off values in older patients with suspected venous thromboembolism: systematic review and meta-analysis. BMJ 346:f2492

    Article  PubMed Central  PubMed  Google Scholar 

  8. Righini M, Van ES J, Den Exter PL, Roy PM et al (2014) Age-adjusted D-dimer cutoff levels to rule out pulmonary embolism: the ADJUST-PE study. JAMA 311:1117–1124

    Article  CAS  PubMed  Google Scholar 

  9. Carrier M, Righini M, Djurabi RK, Huisman MV et al (2009) VIDAS D-dimer in combination with clinical pre-test probability to rule out pulmonary embolism. A systematic review of management outcome studies. Thromb Haemost 101:886–892

    CAS  PubMed  Google Scholar 

  10. Dentali F, Ageno W, Becattini C, Galli L et al (2010) Prevalence and clinical history of incidental, asymptomatic pulmonary embolism: a meta-analysis. Thromb Res 125:518–522

    Article  CAS  PubMed  Google Scholar 

  11. Kearon C, Akl EA, Comerota AJ, Prandoni P et al (2012) Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 141:e419S–494S

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  12. Aujesky D, Obrosky DS, Stone RA, Auble TE et al (2005) Derivation and validation of a prognostic model for pulmonary embolism. Am J Respir Crit Care Med 172:1041–1046

    Article  PubMed Central  PubMed  Google Scholar 

  13. Jimenez D, Aujesky D, Moores L, Gomez V et al (2010) Simplification of the pulmonary embolism severity index for prognostication in patients with acute symptomatic pulmonary embolism. Arch Intern Med 170:1383–1389

    Article  PubMed  Google Scholar 

  14. Righini M, Aujesky D, Roy PM, Cornuz J et al (2004) Clinical usefulness of D-dimer depending on clinical probability and cutoff value in outpatients with suspected pulmonary embolism. Arch Intern Med 164:2483–2487

    Article  PubMed  Google Scholar 

  15. Buller HR, Prins MM, Lensin AW, Decousus H et al (2012) Oral rivaroxaban for the treatment of symptomatic pulmonary embolism. N Engl J Med 366:1287–1297

    Article  PubMed  Google Scholar 

  16. Agnelli G, Buller HR, Cohen A, Curto M et al (2013) Oral apixaban for the treatment of acute venous thromboembolism. N Engl J Med 369:799–808

    Article  CAS  PubMed  Google Scholar 

  17. Schulman S, Kearon C, Kakkar AK, Mismetti P et al (2009) Dabigatran versus warfarin in the treatment of acute venous thromboembolism. N Engl J Med 361:2342–2352

    Article  CAS  PubMed  Google Scholar 

  18. Schulman S, Kakkar AK, Goldhaber SZ, Schellong S et al (2014) Treatment of acute venous thromboembolism with dabigatran or warfarin and pooled analysis. Circulation 129:764–772

    Article  CAS  PubMed  Google Scholar 

  19. Bauersachs R, Berkowitz SD, Brenner B, Buller HR et al (2010) Oral rivaroxaban for symptomatic venous thromboembolism. N Engl J Med 363:2499–2510

    Article  CAS  PubMed  Google Scholar 

  20. Buller HR, Decousus H, Grosso MA, Mercuri M et al (2013) Edoxaban versus warfarin for the treatment of symptomatic venous thromboembolism. N Engl J Med 369:1406–1415

    Article  PubMed  Google Scholar 

  21. Van Der Hulle T, Kooiman J, Den Exter PL, Dekkers OM et al (2014) Effectiveness and safety of novel oral anticoagulants as compared with vitamin K antagonists in the treatment of acute symptomatic venous thromboembolism: a systematic review and meta-analysis. J Thromb Haemost 12:320–328

    Article  CAS  PubMed  Google Scholar 

  22. Agnelli G, Buller HR, Cohen A, Curto M et al (2013) Apixaban for extended treatment of venous thromboembolism. N Engl J Med 368:699–708

    Article  CAS  PubMed  Google Scholar 

  23. Schulman S, Kearon C, Kakkar AK, Schellong S et al (2013) Extended use of dabigatran, warfarin, or placebo in venous thromboembolism. N Engl J Med 368:709–718

    Article  CAS  PubMed  Google Scholar 

  24. Lee AY, Levine MN, Baker RI, Bowden C et al (2003) Low-molecular-weight heparin versus a coumarin for the prevention of recurrent venous thromboembolism in patients with cancer. N Engl J Med 349:146–153

    Article  CAS  PubMed  Google Scholar 

  25. Chatterjee S, Chakraborty A, Weinberg I, Kadakia M et al (2014) Thrombolysis for pulmonary embolism and risk of all-cause mortality, major bleeding, and intracranial hemorrhage: a meta-analysis. JAMA 311:2414–2421

    Article  PubMed  Google Scholar 

  26. Meyer G, Vicaut E, Danays T, Agnelli G et al (2014) Fibrinolysis for patients with intermediate-risk pulmonary embolism. N Engl J Med 370:1402–1411

    Article  CAS  PubMed  Google Scholar 

  27. Simonneau G, Gatzoulis MA, Adatia I, Celermajer D et al (2013) Updated clinical classification of pulmonary hypertension. J Am Coll Cardiol 62:D34–D41

    Article  PubMed  Google Scholar 

  28. Lang IM, Pesavento R, Bonderman D, Yuan JX (2013) Risk factors and basic mechanisms of chronic thromboembolic pulmonary hypertension: a current understanding. Eur Respir J 41:462–468

    Article  PubMed  Google Scholar 

  29. Tunariu N, Gibbs SJ, Win Z, Gin-Sing W et al (2007) Ventilation-perfusion scintigraphy is more sensitive than multidetector CTPA in detecting chronic thromboembolic pulmonary disease as a treatable cause of pulmonary hypertension. J Nucl Med 48:680–684

    Article  PubMed  Google Scholar 

  30. Mayer E, Jenkins D, Lindner J, D’armini A et al (2011) Surgical management and outcome of patients with chronic thromboembolic pulmonary hypertension: results from an international prospective registry. J Thorac Cardiovasc Surg 141:702–710

    Article  PubMed  Google Scholar 

  31. Papamatheakis DG, Kim NH (2015) Advances in the management of chronic thromboembolic pulmonary hypertension. Curr Hypertens Rep 17:582

    Article  PubMed  Google Scholar 

  32. Chan WS, Chunilal S, Lee A, Crowther M et al (2007) A red blood cell agglutination D-dimer test to exclude deep venous thrombosis in pregnancy. Ann Intern Med 147:165–170

    Article  PubMed  Google Scholar 

  33. Heit JA, Silverstein MD, Mohr DN, Petterson TM et al (2000) Risk factors for deep vein thrombosis and pulmonary embolism: a population-based case-control study. Arch Intern Med 160:809–815

    Article  CAS  PubMed  Google Scholar 

  34. Cronin-Fenton DP, Sondergaard F, Pedersen LA, Fryzek JP et al (2010) Hospitalisation for venous thromboembolism in cancer patients and the general population: a population-based cohort study in Denmark, 1997–2006. Br J Cancer 103:947–953

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  35. Palumbo A, Cavo M, Bringhen S, Zamagni E et al (2011) Aspirin, warfarin, or enoxaparin thromboprophylaxis in patients with multiple myeloma treated with thalidomide: a phase III, open-label, randomized trial. J Clin Oncol 29:986–993

    Article  CAS  PubMed  Google Scholar 

  36. Lyman GH, Khorana AA, Falanga A, Clarke-Pearson D et al (2007) American Society of Clinical Oncology guideline: recommendations for venous thromboembolism prophylaxis and treatment in patients with cancer. J Clin Oncol 25:5490–5505

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Klinik für Innere Medizin III, Kardiologie, Angiologie und internistische Intensivmedizin, Universitätsklinikum des Saarlandes, 66421, Homburg/Saar, Deutschland

    J.A. Saar &  C. Maack

Authors
  1. J.A. Saar
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. C. Maack
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to C. Maack.

Ethics declarations

Interessenkonflikt

J.A. Saar gibt an, dass kein Interessenkonflikt besteht. C. Maack erhielt Vortragshonorare von Bayer, Pfizer, Bristol-Myers-Squibb und Boehringer Ingelheim.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

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

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00059-015-4378-0

Schlüsselwörter

Keywords

Search

Navigation