Thromboseprophylaxe bei chirurgischen und nicht chirurgischen Patienten^[*]

Zusammenfassung

Eine routinemäßige Thromboseprophylaxe ist fester Bestandteil der Versorgung chirurgischer und orthopädischer Patienten und gewinnt bei internistischen Patienten an Bedeutung. Trotzdem sind Fragen zur Indikation, zu Art und Umfang der Prophylaxe sowie zu den Möglichkeiten der Verbesserung offen. Zur Indikationsstellung hat sich eine klinisch orientierte Risikoabschätzung bewährt, die expositionelle und dispositionelle Risikofaktoren berücksichtigt. Das expositionelle Risiko ist durch Art und Umfang des chirurgischen Eingriffs bzw. des Traumas charakterisiert, das dispositionelle Risiko hingegen durch patientenbezogene Faktoren. Dies wird auch in nationalen und internationalen Leitlinien beschrieben. Die Wahl der Prophylaxe resultiert aus der Kombination der expositionellen und dispositionellen Risikofaktoren.

Zur VTE-Prophylaxe stehen physikalische und medikamentöse Maßnahmen zur Verfügung. Die tragenden Säulen der medikamentösen Prophylaxe waren bisher einmal tägliche subkutane Verabreichungen von niedermolekularen Heparinpräparaten oder Fondaparinux. Seit kurzem stehen für Hochrisikopatienten mit elektiven Hüft- oder Kniegelenkersatzoperationen auch orale direkte Thrombin- und Faktor- Xa-Inhibitoren zur Verfügung.

Summary

Prevention of deep vein thrombosis has become standard of care in surgical and orthopaedic patients and it is gaining in attention in medical patients. However, there are still open questions related to its indication, to type and extent of prophylaxis and how to improve its efficacy and safety. In order to facilitate decision making to provide or to withhold prophylaxis, clinical risk assessment considering exposing and predisposing risk factors has proved to be of value. The exposing risk is characterised by type and extent of surgery or trauma, respectively, whereas the predisposing risk is determined by patient related risk factors. This has also been acknowledged in national and international guidelines. The choice of prophylactic modalities should be based on the combination of exposing and predisposing risk factors.

Physical and pharmacological methods are available for primary prevention of VTE. The cornerstones of pharma -cological prophylaxis have been subcutaneous injections of low molecular weight heparins or fondaparinux. Recently, also oral direct thrombin- and factor Xa-inhibitors have become available for patients undergoing hip or knee replacement surgery who always are at high risk for VTE complications .

Schlüsselwörter

Thromboembolieprophylaxe - Risikofaktoren - Heparine - Fondaparinux - Thrombininhibitoren - Faktor-Xa-Inhibitoren

Keywords

Prevention of thromboembolism - risk factors - heparins - fondaparinux - thrombin inhibitors - factor Xa inhibitors

^* Diese Arbeit enthält wesentliche Teile einer CMEBeilage des Springer-Verlags. Die Publikation erfolgt mit freundlicher Genehmigung des Springer-Verlags, Heidelberg.

• References

• 1 Geerts WH, Bergqvist D, Pineo GF, Heit JA. et al. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8^th ed). Chest 2008; 133 (Suppl. 06) 381S-453S.
• 2 Haas S. Prevention of deep vein thrombosis in surgical departments. Der Chirurg 2004; 75: 323-43.
• 3 Kakkar VV. Low dose heparin in the prevention of venous thromboembolism. Rationale and results. Thromb Diath Haemorrhagica 1975; 33: 87-96.
• 4 Stangier J, Rathgen K, Stahle H. et al. The pharmacokinetics, pharmacodynamics and tolerability of dabigatran etexilate, a new oral direct thrombin inhibitor, in healthy male subjects. Br J Clin Pharmacol 2007; 64: 292-303.
• 5 Eriksson BI, Dahl OE, Rosencher N. et al. Dabigatran etexilate versus enoxaparin for prevention of venous thromboembolism after total hip replacement: a randomised, double-blind, non-inferiority trial. Lancet 2007; 370 9591 949-956.
• 6 Eriksson BI, Dahl OE, Rosencher N. et al. Oral dabigatran etexilate vs. subcutaneous enoxaparin for the prevention of venous thromboembolism after total knee replacement: the RE-MODEL randomized trial. J Thromb Haemost 2007; 5: 2178-2185.
• 7 Kubitza D, Haas S. Novel factor Xa inhibitors for prevention and treatment of thromboembolic diseases. Expert Opin Invest Drugs 2006; 15: 843-855.
• 8 Eriksson BI, Borris LC, Friedman RJ. et al. Rivaroxaban versus enoxaparin for thromboprophylaxis after hip arthroplasty. N Engl J Med 2008; 358: 2765-2775.
• 9 Kakkar AK, Brenner B, Dahl OE. et al. Extended duration rivaroxaban versus short-term enoxa parin for the prevention of venous thromboembolism after total hip arthroplasty: a double-blind, randomised controlled trial. Lancet 2008; 372 9632 31-39.
• 10 Lassen MR, Ageno W, Borris LC. et al. Rivaroxaban versus enoxaparin for thromboprophylaxis after total knee arthroplasty. N Engl J Med 2008; 358: 2776-2786.
• 11 Collins R, Scrimgeour A, Yusuf S, Peto R. Reduction in fatal pulmonary embolism and venous thrombosis by perioperative administration of subcutaneous heparin. Overview of results of randomized trials in general, orthopedic, and urologic surgery. N Engl J Med 1988; 318: 1162-1173.
• 12 Samama MM, Cohen AT, Darmon JY. et al. A comparison of enoxaparin with placebo for the prevention of venous thromboembolism in acutely ill medical patients. Prophylaxis in Medical Patients with Enoxaparin Study Group. N Engl J Med 1999; 341 (Suppl. 11) 793-800.
• 13 Cohen AT, Davidson BL, Gallus AS. et al. Efficacy and safety of fondaparinux for the prevention of venous thromboembolism in older acute medical patients: randomised placebo controlled trial. Br Med J 2006; 332 7537 325-329.
• 14 Leizorovicz A, Cohen AT, Turpie AG. et al. Randomized, placebo-controlled trial of dalteparin for the prevention of venous thromboembolism in acutely ill medical patients. Circulation 2004; 110: 874-879.
• 15 Sandercock PA, Counsell C, Tseng MC. Low-molecular-weight heparins or heparinoids versus standard unfractionated heparin for acute ischaemic stroke. Cochrane database of systematic reviews (Online) 2008; 3: CD000119.
• 16 Hull RD, Pineo GF, Stein PD. et al. Extended out-of-hospital low-molecular-weight heparin prophylaxis against deep venous thrombosis in patients after elective hip arthroplasty: a systematic review. Ann Intern Med 2001; 135: 858-869.