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Der Klinikarzt 2019; 48(10): 384-395
DOI: 10.1055/a-1011-9023
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© Georg Thieme Verlag Stuttgart · New York

Update Lungenarterienembolie

Aktuelle diagnostische und therapeutische Entwicklungen und Perspektiven
Fabian Stimpfle
1   Medizinische Klinik III, Abteilung für Kardiologie und Kreislauferkrankungen, Tübingen
,
Tobias Geisler
1   Medizinische Klinik III, Abteilung für Kardiologie und Kreislauferkrankungen, Tübingen
› Author Affiliations
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Publication History

Publication Date:
17 October 2019 (online)

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ZUSAMMENFASSUNG

Die korrekte Behandlung der Lungenarterienembolie beginnt mit einer frühzeitigen multimodalen Einschätzung des Risikos unter Berücksichtigung der klinischen Vorhersagekraft, Laborparametern und bildmorphologischen Risikomerkmalen. Während die Lysetherapie hauptsächlich Patienten mit Schocksituation vorbehalten ist, kann sie bei ausgewählten stabilen Patienten mit intermediär hohem Risiko und vertretbarem Blutungsrisiko ebenfalls in Betracht gezogen werden. Im Niedrigrisikobereich ist eine ambulante Behandlung vertretbar. Neue Aspekte umfassen auch den Einsatz von kathetergestützen Reperfusionsmaßnahmen, sowie Algorithmen, um das Langzeitrezidivrisiko als auch die Entwicklung einer chronisch thrombembolischen pulmonalen Hypertonie frühzeitig zu erkennen. Der Vorteil der verlängerten Sekundärprophylaxe nach Lungenarterienembolie ist bei bestimmten Patienten durch Anwendung von klinischen Vorhersagemodellen und auch im Bereich der Tumorerkrankungen durch aktuelle Studiendaten belegt worden. Dieser Übersichtsartikel dient als Update unter Berücksichtigung der aktuellen Entwicklung und liefert Perspektiven über derzeit laufende Studien zur Klärung von offenen Fragen in der Behandlung der Lungenarterienembolie.

 

  • Literatur

  • 1 Kupp S, Pöss J. Bedeutung von Biomarkern bei der Lungenarterienembolie. Internist 2019; 60: 571-577
    CrossrefPubMedGoogle Scholar
  • 2 Righini M, Van Es J, Den Exter PL. et al Age-Adjusted D-Dimer Cutoff Levels to Rule Out Pulmonary Embolism: The ADJUST-PE Study. JAMA 2014; 311: 1117
    CrossrefPubMedGoogle Scholar
  • 3 Schoepf UJ, Holzknecht N, Helmberger TK. et al Subsegmental Pulmonary Emboli: Improved Detection with Thin-Collimation Multi–Detector Row Spiral CT. Radiology 2002; 222: 483-490
    CrossrefPubMedGoogle Scholar
  • 4 Le Roux P-Y, Robin P, Delluc A. et al V/Q SPECT interpretation for pulmonary embolism diagnosis: which criteria to use?. J Nucl Med 2013; 54: 1077-1081
    CrossrefPubMedGoogle Scholar
  • 5 Gutte H, Mortensen J, Jensen CV. et al Comparison of V/Q SPECT and planar V/Q lung scintigraphy in diagnosing acute pulmonary embolism. Nucl Med Commun 2010; 31: 82-86
    CrossrefPubMedGoogle Scholar
  • 6 Simanek M, Koranda P. The benefit of personalized hybrid SPECT/CT pulmonary imaging. Am J Nucl Med Mol Imaging 2016; 6: 215-222
    PubMedGoogle Scholar
  • 7 Tsuchiya N, Beek EJ van, Ohno Y. et al Magnetic resonance angiography for the primary diagnosis of pulmonary embolism: A review from the international workshop for pulmonary functional imaging. World J Radiol 2018; 10: 52-64
    CrossrefPubMedGoogle Scholar
  • 8 Le Roux P-Y, Iravani A, Callahan J. et al Independent and incremental value of ventilation/perfusion PET/CT and CT pulmonary angiography for pulmonary embolism diagnosis: results of the PECAN pilot study. Eur J Nucl Med Mol Imaging. [Internet]. 2019 May 1 [cited 2019 Jun 13]; Available from: http://link.springer.com/10.1007/s00259-019-04338-z
    PubMedGoogle Scholar
  • 9 Konstantinides SV, Torbicki A, Agnelli G. et al 2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J 2014; 35: 3033-3080
    CrossrefPubMedGoogle Scholar
  • 10 Barco S, Lankeit M, Binder H. et al Home treatment of patients with low-risk pulmonary embolism with the oral factor Xa inhibitor rivaroxaban: Rationale and design of the HoT-PE Trial. Thromb Haemost 2016; 116: 191-197
    Article in Thieme ConnectPubMedGoogle Scholar
  • 11 Wan S, Quinlan DJ, Agnelli G. et al Thrombolysis Compared With Heparin for the Initial Treatment of Pulmonary Embolism: A Meta-Analysis of the Randomized Controlled Trials. Circulation 2004; 110: 744-749
    CrossrefPubMedGoogle Scholar
  • 12 Meyer G, Vicaut E, Danays T. et al Fibrinolysis for Patients with Intermediate-Risk Pulmonary Embolism. N Engl J Med 2014; 370: 1402-1411
    CrossrefPubMedGoogle Scholar
  • 13 Konstantinides SV, Vicaut E, Danays T. et al Impact of Thrombolytic Therapy on the Long-Term Outcome of Intermediate-Risk Pulmonary Embolism. J Am Coll Cardiol 2017; 69: 1536-1544
    PubMedGoogle Scholar
  • 14 Wang C, Zhai Z, Yang Y. et al Efficacy and Safety of Low Dose Recombinant Tissue-Type Plasminogen Activator for the Treatment of Acute Pulmonary Thromboembolism. Chest 2010; 137: 254-262
    CrossrefPubMedGoogle Scholar
  • 15 Sharifi M, Bay C, Skrocki L. et al Moderate Pulmonary Embolism Treated With Thrombolysis (from the “MOPETT” Trial). Am J Cardiol 2013; 111: 273-277
    CrossrefPubMedGoogle Scholar
  • 16 Lungenembolie (LE) Vasa. 2016; 45 (Suppl. 90) 27-38
    PubMedGoogle Scholar
  • 17 The EINSTEIN–PE Investigators Oral Rivaroxaban for the Treatment of Symptomatic Pulmonary Embolism. N Engl J Med 2012; 366: 1287-1297
    CrossrefPubMedGoogle Scholar
  • 18 Agnelli G, Buller HR, Cohen A. et al Oral Apixaban for the Treatment of Acute Venous Thromboembolism. N Engl J Med 2013; 369: 799-808
    CrossrefPubMedGoogle Scholar
  • 19 The Hokusai-VTE Investigators Edoxaban versus Warfarin for the Treatment of Symptomatic Venous Thromboembolism. N Engl J Med 2013; 369: 1406-1415
    CrossrefPubMedGoogle Scholar
  • 20 Connolly SJ, Crowther M, Eikelboom JW. et al Full Study Report of Andexanet Alfa for Bleeding Associated with Factor Xa Inhibitors. N Engl J Med 2019; 380: 1326-1335
    CrossrefPubMedGoogle Scholar
  • 21 Schulman S, Kearon C, Kakkar AK. et al Dabigatran versus Warfarin in the Treatment of Acute Venous Thromboembolism. N Engl J Med 2009; 361: 2342-2352
    CrossrefPubMedGoogle Scholar
  • 22 Schulman S, Kakkar AK, Goldhaber SZ. et al Treatment of Acute Venous Thromboembolism With Dabigatran or Warfarin and Pooled Analysis. Circulation 2014; 129: 764-772
    CrossrefPubMedGoogle Scholar
  • 23 Kearon C, Akl EA, Ornelas J. et al Antithrombotic Therapy for VTE Disease. Chest 2016; 149: 315-352
    CrossrefPubMedGoogle Scholar
  • 24 Kucher N, Boekstegers P, Müller OJ. et al Randomized, Controlled Trial of Ultrasound-Assisted Catheter-Directed Thrombolysis for Acute Intermediate-Risk Pulmonary Embolism. Circulation 2014; 129: 479-486
    CrossrefPubMedGoogle Scholar
  • 25 Piazza G, Hohlfelder B, Jaff MR. et al A Prospective, Single-Arm, Multicenter Trial of Ultrasound-Facilitated, Catheter-Directed, Low-Dose Fibrinolysis for Acute Massive and Submassive Pulmonary Embolism. JACC Cardiovasc Interv 2015; 8: 1382-1392
    CrossrefPubMedGoogle Scholar
  • 26 Engelberger RP, Moschovitis A, Fahrni J. et al Fixed low-dose ultrasound-assisted catheter-directed thrombolysis for intermediate and high-risk pulmonary embolism. Eur Heart J 2015; 36 (10) 597-604
    CrossrefPubMedGoogle Scholar
  • 27 Tu T, Toma C, Tapson VF. et al A Prospective, Single-Arm, Multicenter Trial of Catheter-Directed Mechanical Thrombectomy for Intermediate-Risk Acute Pulmonary Embolism. JACC Cardiovasc Interv 2019; 12: 859-869
    CrossrefPubMedGoogle Scholar
  • 28 Zuin M, Rigatelli G, Zonzin P. et al Inferior Vena Cava Filters in Hemodynamically Unstable Patients with Acute Pulmonary Embolism: How Often are They Used? Data from Multicenter Prospective Registries on Acute Pulmonary Embolism. Cardiovasc Intervent Radiol [Internet]. 2019 May 15 [cited 2019 Jun 13]; Available from: http://link.springer.com/10.1007/s00270-019-02242-5
    PubMedGoogle Scholar
  • 29 Lee T, Itagaki S, Chiang YP. et al Survival and recurrence after acute pulmonary embolism treated with pulmonary embolectomy or thrombolysis in New York State, 1999 to 2013. J Thorac Cardiovasc Surg 2018; 155: 1084-1090.e12
    CrossrefPubMedGoogle Scholar
  • 30 Keeling WB, Leshnower BG, Lasajanak Y. et al Midterm benefits of surgical pulmonary embolectomy for acute pulmonary embolus on right ventricular function. J Thorac Cardiovasc Surg 2016; 152: 872-878
    CrossrefPubMedGoogle Scholar
  • 31 Agnelli G, Prandoni P, Santamaria MG. et al Three Months versus One Year of Oral Anticoagulant Therapy for Idiopathic Deep Venous Thrombosis. N Engl J Med 2001; 345: 165-169
    CrossrefPubMedGoogle Scholar
  • 32 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
    CrossrefPubMedGoogle Scholar
  • 33 Couturaud F, Sanchez O, Pernod G. et al Six Months vs Extended Oral Anticoagulation After a First Episode of Pulmonary Embolism: The PADIS-PE Randomized Clinical Trial. JAMA 2015; 314: 31
    CrossrefPubMedGoogle Scholar
  • 34 Eichinger S, Heinze G, Jandeck LM. et al Risk Assessment of Recurrence in Patients With Unprovoked Deep Vein Thrombosis or Pulmonary Embolism: The Vienna Prediction Model. Circulation 2010; 121: 1630-1636
    CrossrefPubMedGoogle Scholar
  • 35 Becattini C, Giustozzi M, Cerdà P. et al Risk of recurrent venous thromboembolism after acute pulmonary embolism: Role of residual pulmonary obstruction and persistent right ventricular dysfunction. A meta-analysis. J Thromb Haemost 2019; 17: 1217-1228
    CrossrefPubMedGoogle Scholar
  • 36 Palareti G, Cosmi B, Legnani C. et al D-dimer to guide the duration of anticoagulation in patients with venous thromboembolism: a management study. Blood 2014; 124: 196-203
    PubMedGoogle Scholar
  • 37 Cosmi B, Legnani C, Tosetto A. et al Usefulness of repeated D-dimer testing after stopping anticoagulation for a first episode of unprovoked venous thromboembolism: the PROLONG II prospective study. Blood 2010; 115: 481-488
    CrossrefPubMedGoogle Scholar
  • 38 Le Moigne E, Timsit S, Ben Salem D. et al Patent Foramen Ovale and Ischemic Stroke in Patients With Pulmonary Embolism: A Prospective Cohort Study. Ann Intern Med 2019; 170: 756
    CrossrefPubMedGoogle Scholar
  • 39 Pengo V, Denas G, Zoppellaro G. et al Rivaroxaban vs warfarin in high-risk patients with antiphospholipid syndrome. Blood 2018; 132: 1365-1371
    CrossrefPubMedGoogle Scholar
  • 40 Brown JD, Goodin AJ, Lip GYH. et al Risk Stratification for Bleeding Complications in Patients With Venous Thromboembolism: Application of the HAS-BLED Bleeding Score During the First 6 Months of Anticoagulant Treatment. J Am Heart Assoc [Internet]. 2018 Mar 20 [cited 2019 Jun 18];7. Available from: https://www.ahajournals.org/doi/10.1161/JAHA.117.007901
    PubMedGoogle Scholar
  • 41 Klok FA, Hösel V, Clemens A. et al Prediction of bleeding events in patients with venous thromboembolism on stable anticoagulation treatment. Eur Respir J 2016; 48: 1369-1376
    CrossrefPubMedGoogle Scholar
  • 42 Schulman S, Kearon C, Kakkar AK. et al Extended Use of Dabigatran, Warfarin, or Placebo in Venous Thromboembolism. N Engl J Med 2013; 368: 709-718
    CrossrefPubMedGoogle Scholar
  • 43 Agnelli G, Buller HR, Cohen A. et al Apixaban for Extended Treatment of Venous Thromboembolism. N Engl J Med 2013; 368: 699-708
    CrossrefPubMedGoogle Scholar
  • 44 Raskob G, Ageno W, Cohen AT. et al Extended duration of anticoagulation with edoxaban in patients with venous thromboembolism: a post-hoc analysis of the Hokusai-VTE study. Lancet Haematol 2016; 3: e228-e236
    PubMedGoogle Scholar
  • 45 Eichinger S, Heinze G, Kyrle PA. d-Dimer Levels Over Time and the Risk of Recurrent Venous Thromboembolism: An Update of the Vienna Prediction Model. J Am Heart Assoc [Internet]. 2014 Jan 27 [cited 2019 Jun 28];3(1). Available from: https://www.ahajournals.org/doi/10.1161/JAHA.113.000467
    PubMedGoogle Scholar
  • 46 Rodger MA, Kahn SR, Wells PS. et al Identifying unprovoked thromboembolism patients at low risk for recurrence who can discontinue anticoagulant therapy. Can Med Assoc J 2008; 179: 417-426
    CrossrefPubMedGoogle Scholar
  • 47 Tosetto A, Iorio A, Marcucci M. et al Predicting disease recurrence in patients with previous unprovoked venous thromboembolism: a proposed prediction score (DASH): Clinical prediction of VTE recurrence. J Thromb Haemost 2012; 10: 1019-1025
    CrossrefPubMedGoogle Scholar
  • 48 Sallah S, Wan JY, Nguyen NP. Venous thrombosis in patients with solid tumors: determination of frequency and characteristics. Thromb Haemost 2002; 87: 575-579
    Article in Thieme ConnectPubMedGoogle Scholar
  • 49 Carrier M, Lazo-Langner A, Shivakumar S. et al Screening for Occult Cancer in Unprovoked Venous Thromboembolism. N Engl J Med 2015; 373: 697-704
    CrossrefPubMedGoogle Scholar
  • 50 van Herk-Sukel MPP, Shantakumar S, Penning-van Beest FJA. et al Pulmonary Embolism, Myocardial Infarction, and Ischemic Stroke in Lung Cancer Patients: Results from a Longitudinal Study. Lung 2013; 191: 501-509
    CrossrefPubMedGoogle Scholar
  • 51 Heit JA, O’Fallon WM, Petterson TM. et al Relative impact of risk factors for deep vein thrombosis and pulmonary embolism: a population-based study. Arch Intern Med 2002; 162: 1245-1248
    CrossrefPubMedGoogle Scholar
  • 52 Lee AYY, Kamphuisen PW, Meyer G. et al Tinzaparin vs Warfarin for Treatment of Acute Venous Thromboembolism in Patients With Active Cancer: A Randomized Clinical Trial. JAMA 2015; 314: 677
    CrossrefPubMedGoogle Scholar
  • 53 van der Hulle T, den Exter PL, Kooiman J. et al Meta-analysis of the efficacy and safety of new oral anticoagulants in patients with cancer-associated acute venous thromboembolism. J Thromb Haemost 2014; 12: 1116-1120
    CrossrefPubMedGoogle Scholar
  • 54 Vedovati MC, Germini F, Agnelli G. et al Direct Oral Anticoagulants in Patients With VTE and Cancer. Chest 2015; 147: 475-483
    CrossrefPubMedGoogle Scholar
  • 55 Raskob GE, van Es N, Segers A. et al Edoxaban for venous thromboembolism in patients with cancer: results from a non-inferiority subgroup analysis of the Hokusai-VTE randomised, double-blind, double-dummy trial. Lancet Haematol 2016; 3: e379-387
    CrossrefPubMedGoogle Scholar
  • 56 Raskob GE, van Es N, Verhamme P. et al Edoxaban for the Treatment of Cancer-Associated Venous Thromboembolism. N Engl J Med 2018; 378: 615-624
    CrossrefPubMedGoogle Scholar
  • 57 Lee JH, Hyun D, Choi CM. et al A Retrospective Study on Efficacy and Safety of Rivaroxaban and Dalteparin for Long-Term Treatment of Venous Thromboembolism in Patients with Lung Cancer. Respiration 2019; 16: 1-9
    PubMedGoogle Scholar
  • 58 Young AM, Marshall A, Thirlwall J. et al Comparison of an Oral Factor Xa Inhibitor With Low Molecular Weight Heparin in Patients With Cancer With Venous Thromboembolism: Results of a Randomized Trial (SELECT-D). J Clin Oncol 2018; 36: 2017-2023
    CrossrefPubMedGoogle Scholar
  • 59 Khorana AA, Soff GA, Kakkar AK. et al Rivaroxaban for Thromboprophylaxis in High-Risk Ambulatory Patients with Cancer. N Engl J Med 2019; 380: 720-728
    CrossrefPubMedGoogle Scholar
  • 60 Carrier M, Abou-Nassar K, Mallick R. et al Apixaban to Prevent Venous Thromboembolism in Patients with Cancer. N Engl J Med 2019; 380: 711-719
    CrossrefPubMedGoogle Scholar
  • 61 Galiè N, Humbert M, Vachiery J-L. et al 2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension: The Joint Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS)Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC), International Society for Heart and Lung Transplantation (ISHLT). Eur Heart J 2016; 37: 67-119
    CrossrefPubMedGoogle Scholar
  • 62 Sugimura K, Fukumoto Y, Satoh K. et al Percutaneous transluminal pulmonary angioplasty markedly improves pulmonary hemodynamics and long-term prognosis in patients with chronic thromboembolic pulmonary hypertension. Circ J 2012; 76: 485-488
    CrossrefPubMedGoogle Scholar