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Kommentar zu den ESC-Leitlinien „Guidelines on Diagnosis and Management of Acute Pulmonary Embolism“

Commentary on the ESC Guidelines on Diagnosis and Management of Acute Pulmonary Embolism

  • Leitlinien
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Der Kardiologe Aims and scope

Zusammenfassung

Jährlich versterben schätzungsweise 40.000 Patienten in Deutschland an einer akuten Lungenembolie (LE). Die neue (2008) ESC-Leitlinie stellt den klinischen Schweregrad, nämlich das LE-bedingte Todes- oder Komplikationsrisiko, in den Vordergrund empfohlener Management-Konzepte. So stellen hämodynamisch instabile Patienten mit Verdacht auf Hochrisiko-LE einen medizinischen Notfall dar. Die CT-Pulmonalisangiographie (CTPA) oder Echokardiographie kann die LE bestätigen und die Indikation zur Thrombolyse/Embolektomie stellen. Bei normotensiven Patienten (Nicht-Hochrisiko-LE) werden diagnostische Algorithmen auf der Basis der Multidetektor-CTPA bevorzugt. Die initiale Antikoagulation sollte aus niedermolekularem Heparin oder Fondaparinux bestehen. Allerdings profitieren möglicherweise einige normotensive Patienten mit RV-Dysfunktion und/oder myokardialer Schädigung von einer frühen thrombolytischen Behandlung (mittleres Risiko). Die Dauer einer Sekundärprophylaxe (oralen Antikoagulation) nach akuter LE sollte mindestens 3 Monate betragen. Bei stabiler Antikoagulation und niedrigem Blutungsrisiko ist nach unprovozierter LE eine unbefristete Weiterführung der Therapie zu erwägen.

Abstract

As many as 40,000 patients in Germany die of acute pulmonary embolism (PE) each year. The updated (2008) ESC guidelines emphasize the importance of adjusting management strategies to the clinical severity of PE, i.e. the death or complication risk in the acute phase. Haemodynamically unstable patients with suspected high-risk PE should undergo emergency CT pulmonary angiography (CTPA) or, alternatively, echocardiography. If PE is confirmed, thrombolysis or surgical embolectomy should be performed without delay. In normotensive patients (non-high-risk PE), diagnostic algorithms based on multi-detector CTPA are generally preferred. Initial anticoagulation includes low-molecular-weight heparin or fondaparinux. However, selected normotensive patients with right ventricular (RV) dysfunction and/or myocardial injury may benefit from early thrombolysis (intermediate-risk group). Oral anticoagulation for secondary prophylaxis should be continued for at least 3 months. In patients with unprovoked PE, stable INR and low bleeding risk, indefinite anticoagulation may be considered.

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Abbreviations

aPTT:

aktivierte partielle Thromboplastinzeit

BNP:

brain natriuretic peptide

CT:

Computertomographie/-tomogramm

CTPA:

computertomographische Pulmonalisangiographie/-angiogramm

ELISA:

Enzyme-Linked ImmunoSorbent Assay

ESC:

European Society of Cardiology/Europäische Gesellschaft für Kardiologie

H-FABP:

Heart-type Fatty Acid-Binding Protein

HIT:

Heparininduzierte Thrombozytopenie

INR:

International Normalized Ratio

KUS:

Kompressionsultrasonographie/-sonogramm

LE:

Lungenembolie

MDCT:

Multidetektor-Computertomographie/-tomogramm

NMH:

niedermolekulare Heparine

NT-proBNP:

N-terminal proBNP

NYHA:

New York Heart Association

PIOPED:

Prospective Investigation On Pulmonary Embolism Diagnosis

RHK:

Rechtsherzkatheterisierung

RV:

rechter Ventrikel

TVT:

tiefe Venenthrombose

UFH:

unfraktioniertes Heparin

V/Q Scan:

Ventilations-Perfusions-Szintigraphie/-Szintigramm

VKA:

Vitamin-K-Antagonisten

VTE:

venöse Thromboembolie

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Authors and Affiliations

  1. Abteilung Kardiologie und Pneumologie, Universitätsmedizin Göttingen, 37099, Göttingen, Deutschland

    S. Konstantinides & G. Hasenfuß

  2. Abteilung Innere Medizin, St.-Antonius-Hospital Eschweiler, Eschweiler, Deutschland

    U. Janssens

  3. Klinik für Thoraxchirurgie, Katholisches Klinikum Mainz, Mainz, Deutschland

    E. Mayer

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  1. S. Konstantinides
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  2. U. Janssens
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  3. E. Mayer
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  4. G. Hasenfuß
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Correspondence to S. Konstantinides.

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Konstantinides, S., Janssens, U., Mayer, E. et al. Kommentar zu den ESC-Leitlinien „Guidelines on Diagnosis and Management of Acute Pulmonary Embolism“. Kardiologe 3, 272–282 (2009). https://doi.org/10.1007/s12181-009-0195-0

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