Subscribe to RSS
DOI: 10.1055/s-0030-1263323
© Georg Thieme Verlag KG Stuttgart · New York
Die akute Lungenembolie
Acute pulmonary embolismPublication History
eingereicht: 8.4.2010
akzeptiert: 26.8.2010
Publication Date:
07 September 2010 (online)
![](https://www.thieme-connect.de/media/dmw/201037/lookinside/thumbnails/10.1055-s-0030-1263323-1.jpg)
Zusammenfassung
Der Verlauf einer akuten Lungenarterienembolie (LAE) ist gekennzeichnet durch ein breites klinisches Spektrum vom asymptomatischen Verlauf bis zum plötzlichen Herztod, mit einer durchschnittlichen Mortalität von 11 % innerhalb von 2 Wochen. Aufgrund der potentiellen vitalen Bedrohung muss jeder klinische Verdacht auf eine Lungenembolie definitiv abgeklärt werden. Das Mortalitätsrisiko von Patienten mit LAE lässt sich auf Basis ihrer hämodynamischen Instabilität abschätzen. Unterschieden wird eine Hoch-Risiko-Gruppe (30-Tage Mortalität > 15 %) und eine Nicht-Hochrisiko-Gruppe (30-Tage Mortalität < 15 %). Empfohlen wird ein Risiko-adaptiertes Patientenmanagement, wobei sich der diagnostische und der therapeutische Algorithmus zwischen den beiden Gruppen erheblich unterscheidet. Patienten mit Verdacht auf Hochrisiko-LAE sind ein medizinischer Notfall, mit der Notwendigkeit einer umgehenden Diagnostik mittels Multidetector-CT-Pulmonalisangiographie (MD-CTPA) oder Echokardiographie sowie ggf. prompter Durchführung einer rekanalisierenden Therapie (Thrombolyse/Embolektomie). Für das Managment von Patienten der Nicht-Hochrisiko-Gruppe hat sich eine schrittweise Diagnostik mit dokumentierter Anwendung eines Wahrscheinlichkeits-Scores etabliert. Die ungezielte Bestimmung von D-Dimeren sollte vermieden werden. Bei Nicht-Hochrisiko-LAE ist die umgehende therapeutische Antikoagulation Therapie der Wahl.
Abstract
Acute pulmonary embolism (APE) presents with a broad clinical spectrum ranging from an even asymptomatic course to sudden cardiac death. Because APE is potentially life-threatening every suspicion of APE has to be clarified promptly by validated diagnostic algorithms. On the basis of the patients haemodynamic instability high-risk APE and non-high-risk APE is differentiated. Based on the presence of shock or hypotension every patient with suspicion of APE should promptly be stratified as high-risk APE or non-high-risk APE. There is a considerable difference in the diagnostic and therapeutic algorithms between high-risk and non-high-risk APE. In suspicion of high-risk APE the patients require immediate diagnosis by multidetector CT or echocardiography and immediate recanalization of the occluded pulmonary arteries by thrombolysis or embolectomy. In haemodynamically stable patients sequential diagnostic workup and prompt therapeutic anticoagulation is recommended.
Schlüsselwörter
Lungenembolie - LAE - venöse Thrombembolie - Thrombolyse
Keywords
pulmonary embolism - APE - venous thrombembolism - thrombolysis
Literatur
- 1 Agnelli G, Becattini C. Acute pulmonary embolism. N Engl J Med. 2010; 363 266-274
- 2 Agnelli G, Prandoni P, Becattini C. et al . Extended oral anticoagulant therapy after a first episode of pulmonary embolism. Ann Intern Med. 2003; 139 19-25
- 3 Anderson D, Barnes D. The use of leg venous ultrasonography for the diagnosis of pulmonary embolism. Semin Nucl Med. 2008; 38 412-417
- 4 Anderson F A, Spencer F A. Risk factors for venous thrombembolism. Circulation. 2003; 107 I-9-I-16
- 5 AWMF online: Leitlinien-Register Nr 065/002: Diagnostik und Therapie der Venenthrombose und der Lungenembolie. Überarbeitete Version von 06/2010.
- 6 Barritt D W, Jordan S C. Anticoagulant drugs in the treatment of pulmonary embolism. A controlled trial Lancet. 1960; 275 1309-1312
- 7 Becattini C, Agnelli G. Predictors of mortality from pulmonary embolism and their influence on clinical management. Thromb Haemost. 2008; 100 747-751
- 8 Becattini C, Vedovati M C, Agnelli G. Prognostic value of troponins in acute pulmonary embolism: a meta-analysis. Circulation. 2007; 116 427-433
- 9 Beyer J, Schellong S. The search for deep vein thrombosis, in Konstantinides S „Management of Acute Pulmonary Embolism”. Humana Press; 2007: 43-55
- 10 Bourjeily G, Paidas M, Khalil H, Montella K R, Rodger M. Pulmonary embolism in pregnancy. Lancet. 2010; 375 500-512
- 11 Capstick T, Henry M T. Efficacy of thrombolytic agents in the treatment of pulmonary embolism. Eur Respir J. 2005; 26 864-674
- 12 Chan W S, Chunilal S, Lee A, Crowther M, Rodger M, Ginsberg J S. A red blood cell agglutination D-Dimer test to exclude deep venous thrombosis in pregnancy. Ann Intern Med. 2007; 147 165-170
- 13 Cohn D, Vansenne F, de Borgie C, Middeldorp S. Thrombophilia testing for prevention of recurrent venous thrombembolism. Cochrane database syst Reviews; 2009 CD007069.
- 14 Crushman M. Epidemiology and risk factors for venous thrombosis. Semin Hematol. 2007; 44 62-69
- 15 Dalen J E. Should patients with venous thrombembolism be screened for thrombophilia?. Am J Med. 2008; 121 458-463
- 16 Dellas C, Puls M, Lankeit M. et al . Elevated heart-type fatty acid-binding protein levels on admission predict an adverse outcome in normotensive patients with acute pulmonary embolism. J Am Coll Cardiol. 2010; 55 2150-2157
- 17 Dong B R, Hao Q, Yue J, Wu T, Liu G J. Thrombolytic therapy for pulmonary embolism The Cochrane Collaboration. The Cochrane Library; 2009 2 CD004437.
- 18 Farmer-Boatwright M, Roubey R. Venous thrombosis in the antiphospholipid syndrome. Arterioscler Thromb Vasc Biol. 2009; 29 321-325
- 19 Fengler B T, Bardy W J. Fibrinolytic therapy in pulmonary embolism: an evidenced based treatment algorithm. Am J Emerg Med. 2009; 27 84-95
- 20 Giannitis E, Müller-Bardorff M, Kurowski V. et al . Independent prognostic value of cardiac Troponin T in patients with confirmed pulmonary embolism. Circulation. 2000; 102 211-217
- 21 Ginsberg J, Wells P S, Kearon C. et al . Sensitivity and specificity of a rapid whole blood assay for d-dimer in the diagnosis of pulmonary embolism. Ann Intern Med. 1988; 129 1006-1011
- 22 Goldhaber S, Haire W, Feldstein M. et al . Alteplase versus heparin in acute pulmonary embolism: randomised trail assessing right-ventricular function and pulmonary perfusion. Lancet. 1993; 341 507-511
- 23 Goldhaber S Z, Visani L, De Rosa M. Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet. 1999; 353 1386-1389
- 24 Heit J A, Kobbervig C, James A H, Petterson T M, Bailey K, Melton L J. Trends in the incidence of venous thrombembolism during pregnancy or postpartum: A 30-year popultion-based study. Ann Intern Med. 2005; 143 697-706
- 25 Heit J A, Mohr D, Silverstein M D, Petterson T, O’Fallon M, Melton J L. Predictors of recurrence after deep vein thrombosis and pulmonary embolism. Arch Intern Med. 2000; 160 761-768
- 26 Heit J A, Silverstein M, Mohr D. et al . Predictors of survival after deep vein thrombosis and pulmonary embolism. Arch Intern Med. 1999; 159 445-453
- 27 Heit J A. The Epidemiology of venous thrombembolism in the communitiy: implications for prevention and management. J Thromb Thrombolysis. 2006; 21 23-29
- 28 Hull R, Raskob G, Brant R, Pineo G, Valentine. The importance of initial heparin treatment on long-term clinical outcomes of antithrombotic therapy: the emerging theme of delayed recurrence. Arch Intern Med. 1997; 157 2317-2321
- 29 Husted S. Treatment of pulmonary embolism at home?. Thrombosis Research. 2010; 126 3-4
- 30 Janjua M, Badsah A, Matta F. et al . Treatment of acute pulmonary embolism as outpatients of following early discharge. Thromb Haemost. 2008; 100 756-761
- 31 Jeres-Sanchez C, Ramirez-Rivera A, de Lourdes G M. et al . Streptokinase and heparin versus heparin alone in massive pulmonary embolism; a randomized controlled trail. J Thromb Thrombolysis. 1995; 2 227-229
- 32 Kasper W, Konstantinides S, Geibel A. et al . Management strategies and determinants of outcome in acute major pulmonary embolism: results of a multicenter registry. J Am Coll Cardiol. 1997; 30 1165-1171
- 33 Kearon C, Kahn S, Agnelli G. et al . Antithrombotic therapy for venous thrombembolic disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008; 133 454-545
- 34 Klok F A, Mos I C, Huisman M V. Brain-type natriuretic peptide levels in the prediction of adverse outcome in patients with pulmonary embolism: a systematic review and metaanalysis. Am J Repir Crit Care Med. 2008; 178 425-430
- 35 Konstantinides S, Geibel A, Heusel G, Heinrich F, Kasper W. Heparin plus alteplase compared with heparin alone in patients with submassive pulmonary embolism. N Engl J Med. 2002; 347 1143-1150
- 36 Konstantinides S, Geibel A, Olschewski M. et al . Importance of cardiac Troponin I and T in risk stratification of patients with acute pulmonary embolism. Circulation. 2002; 106 1263-1268
- 37 Konstantinides S, Janssens U, Mayer E, Hasenfuß G. Kommentar zu den ESC-Leitlinien„Guidelines on Diagnosis and Management of Acute Pulmonary Embolism”. Kardiologe. 2009; 3 272-282
- 38 Konstantinides S. Acute pulmonary embolism. N Engl J Med. 2008; 359 2804-2813
- 39 Kucher N, Rossi E, DeRosa M, Goldhaber S Z. Massive pulmonary embolism. Circulation. 2006; 113 577-582
- 40 Kürkiciyan I, Meron G, Sterz F. et al . Pulmonary embolism as cause of cardiac arrest. Arch Intern Med. 2000; 160 1529-1535
- 41 Lankeit M, Friesen D, Aschoff J. et al . Highly sensitive troponin T assay in normotensive patients with acute pulmonary embolism. Eur Heart J. 2010; 31 1836-1844
- 42 Lankeit M, Konstantinides S. Thrombolysis for pulmonary embolism: past, present and future. Thromb Haemost. 2010; 103 877-883
- 43 Lankeit M. Thrombolysis for hemodynamically stable patients with pulmonary embolism: still searching for the intermediate-risk group. Thrombosis Research. 2009; 124 647-648
- 44 Le Gal G, Righini M, Roy P M. et al . Prediction of pulmonary embolism in the emergency department: the revised Geneva score. Ann Intern Med. 2006; 144 165-171
- 45 Lee A Y, Rickles F R, Julian J A, Gent M, Baker R I, Bowden C. Randomized comparison of low molecular weight heparin and coumarin derivates on the survival of patients with cancer and venous thrombembolism. J Clin Oncol. 2005; 23 2123-2129
- 46 Levine M, Gent M, Hirsh J. et al . A comparison of low-moleular weight heparin administered primarily at home with unfractionated heparin administered in the hospital for proximal deep vein thrombosis. N Eng J Med. 1996; 334 677-681
- 47 Lifjering W M, Brouwer J L, Veeger N J. et al . Selective testing for thrombophilia in patients with first venous thrombosis: results from a retrospective family cohort study on absolute thrombotic risk for currently known thrombophilic defects in 2479 relatives. Blood. 2009; 113 5314-5322
- 48 Lyman G, Khorana A, Falanga A. et al . American Society of Clinical Oncology Guideline: Recommendations for venous thrombembolism prophylaxis and treatment in patients with cancer. J Clin Oncol. 2007; 25 5490-5505
- 49 Marik P E, Plante L A. Venous thrombembolic disease and pregnancy. N Engl J Med. 2008; 359 2025-2033
- 50 Otero R, Trujillo-Santos J, Cayuela A. et al . The Registro Informatizado de la Enfermedad Thromboembolica (RIETE) Investigators: Haemodynamically unstable pulmonary embolism in the RIETE Registry: systolic blood pressure or shock index?. Eur Respir J. 2007; 30 1111-1116
- 51 Otero R, Uresandi F, Jimenez D. et al . Home treatment in pulmonary embolism. Thrombosis Research. 2010; 126 e1-e5
- 52 Perrier A. D-dimer for suspected pulmonary embolism. Chest. 2004; 125 807-809
- 53 Stein P, Fowler S, Lawrence. PIOPED II Investigators . Multidetector Computed Tomography for Acute Pulmonary Embolism. N Engl J Med. 2006; 354 2317-2327
- 54 PIOPED Investigators . Value of the ventilation/perfusion scan in acute pulmonary embolism. Results of the prospective investigation of pulmonary embolism diagnosis (PIOPED). The PIOPED Investigators. JAMA. 1990; 263 2753-2759
- 55 Proudfoot A, Melley D, Shah P. Role of thrombolysis in haemodynamically stable patients with pulmonary embolism. Thorax. 2008; 63 853-854
- 56 Puls M, Dellas C, Lankeit M. et al . Heart-type fatty acid-binding proteins permits early risk stratification of pulmonary embolism. Eur Heart J. 2007; 28 224-229
- 57 Righini M, Aujesky D, Roy P M. et al . Clinical usefulness of D-Dimer depending on clinical probability and cutoff value in outpatients with suspected pulmonary embolism. Ach Intern Med. 2004; 164 2483-2487
- 58 Righini M, Le G al F, Aujesky D. et al . Diagnosis of pulmonary embolism by multidetector CT alone or combined with venous ultrasonography of the leg: a randomised non-inferiority trail. Lancet. 2008; 371 1343-1352
- 59 Rose P S, Punjabi N M, Pearse D B. Treatment of right heart thrombemboli. Chest. 2002; 121 806-14
- 60 Roy P M, Meyer G, Vielle B. et al . Appropiateness of diagnostic management and outcomes of suspected pulmonary embolism. Ann Intern Med. 2006; 144 157-164
- 61 Sanchez O, Trinquart L, Colombet I. et al . Prognostic value of right ventricular dysfunction in patients with haemodynamically stable pulmonary embolism: a systematic review. Eur Heart J. 2008; 29 1569-1577
- 62 Sandler D A, Martin J F. Autopsy proven pulmonary embolism in hospital patients: are we detecting enough deep vein thrombosis?. J R Soc Med. 1989; 82 203-205
- 63 Silverstein M D, Heit J A, Mohr D N, Petterson D M, O’Fallon W M, Melton L J. Trends in the incidence of deep vein thrombosis and pulmonary embolism: a 25-year population-based study. Arch Intern Med. 1998; 158 585-593
- 64 Simpson E L, Stevenson M D, Rawdin A, Papaioannou. Thrombophilia testing in people with venous thrombembolism: Systematic review and cost-effectiveness analysis. Health technol Assess. 2009; 13 1-91
- 65 Smith S B, Geske J, Maguire J, Zane N, Carter R, Morgenthaler T. Early anticoagulation is associated with reduced mortality for acute pulmonary embolism. Chest. 2010; 137 1382-1390
- 66 Squizzato A, Galli M, Dentalli F, Ageno W. Outpatient treatment and early discharge of symptomatic pulmonary embolism: a systematic review. Eur Respir J. 2009; 33 1148-1155
- 67 Stein P, Chenevert T, Fowler S. et al . Gadolinium-enhanced magnetic resonance angiography for pulmonary embolism. (PIOPED III). Ann Intern Med. 2010; 152 434-443
- 68 Stein P, Henry J. Clinical characteristics of patients with acute pulmonary embolism stratified according to their presenting syndromes. CHEST. 1997; 112 974-979
- 69 Stein P, Henry J W. Prevalence of acute pulmonary embolism among patients in a general hospital and at autopsy. Chest. 1995; 108 978-981
- 70 Stein P, Hull R, Matta F, Yaekoub A. Early discharge of patients with venous thrombembolism: Implications Regarding Therapy. Clin Appl Thromb hemost. 2010; 16 141-145
- 71 Tapson V F. Acute Pulmonary Embolism. N Engl J Med. 2008; 358 1037-1052
- 72 Tardy B, Venet C, Zeni F. et al . Short term effect of recombinant plasminogen activator in patients with hemodynamically stable acute pulmonary embolism: Results of a meta-analysis involving 464 patients. Thromb Res. 2009; 124 672-677
- 73 Torbicki A, Perrier A, Konstantinides S. TASK FORCE for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC) . Guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J. 2008; 29 2276-2315
- 74 Ten Wolde M, Söhne M, Quak E. et al . Prognostic value of echocardiographically assessed right ventricular dysfunction in patients with pulmonary embolism. Arch Intern Med. 2004; 164 1685-1689
- 75 To M S, Hunt B J, Nelson-Piercy C. A negative D-dimer does not exclude venous thrombembolism (VTE) in pregnancy. J Obstet Gynaecol. 2008; 28 222-240
- 76 Verstraete M, Miller G A, Bounameaux H. et al . Intravenous and intrapulmonary recombinant tissue-type plasminogen activator in the treatment of acute massive pulmonary embolism. Circulation. 1988; 77 353-360
- 77 Vuilleumier N, Le G al G, Verschuren F. et al . Cardiac biomarkers for risk stratification in non-massive pulmonary embolism: a multi-center propective study. J Thrombosis and Haemostasis. 2008; 7 391-398
- 78 Wan S, Quinlan D, Agnelli G, Eikelboom J. Thrombolysis compared with heparin for the initial treatment of pulmonary embolism. Circulation. 2004; 110 744-749
- 79 Wells P S, Anderson D, Rodger M. et al . Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED-D-dimer. Thromb Haemost. 2000; 83 416-420
- 80 Zheng Z J, Croft J, Giles W, Mensah G. Sudden cardiac death in the United States, 1989 to 1998. Circulation. 2001; 104 2158-2163
- 81 Zhu T, Martinez I, Emmerich J. Venous thrombembolism. Risk factors for recurrence. Arteriocler Thromb Vasc Biol. 2009; 29 298-310
Dr. med. Silke Braun
Medizinische Klinik I – Pneumologie
Universitätsklinikum
Carl-Gustav-Carus Dresden
Fetscherstr. 74
01307 Dresden
Email: Silke.Braun@uniklinikum-dresden.de