Die akute Lungenembolie

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

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