Thromboembolische Erkrankungen aus kardiologischer Sicht

Thromboembolische Erkrankungen können zu kardiologischen Notfällen mit einer hohen Mortalität führen. Deren Erkennung, akute Behandlung und Sekundärprävention stellen daher einen wesentlichen Behandlungsschwerpunkt in der kardiologischen Praxis dar. Dieser Beitrag zeigt das kardiologische Work-up sowie die medikamentöse und interventionelle Therapie bei thromboembolischen Erkrankungen im venösen und im arteriellen Stromgebiet.

Abstract

Thromboembolic disease is associated with a high mortality. It can be divided into two groups: embolism from a venous and embolism from an arterial side. This article gives an overview on thromboembolic disease (with a focus on pulmonary embolism and ischemic stroke) from a cardiologist’s perspective.

The therapeutic options for acute pulmonary embolism range from anticoagulation to fibrinolysis to interventional recanalization and surgery. The deciding factor for choice of therapy is the risk of early death. Besides clinical parameters, laboratory markers like cardiac troponin and right ventricular function on echocardiography or CTPA (computed tomography pulmonary angiography) are used to determine the early mortality risk. In hemodynamically instable patients, immediate thrombolysis is required, whereas patients with intermediate and low risk can be treated with anticoagulation. Interventional recanalization is currently being studied in patients at risk for development of CTEPH (chronic thromboembolic pulmonary hypertension) or an intermediate risk of early mortality.

In ischemic stroke, early interdisciplinary workup involving a cardiologist is paramount. Post stroke screening should include monitoring for arrythmias (especially atrial fibrillation) and transthoracic echocardiography as well as sonography of extra- and intracranial arteries. If no embolic source can be detected (embolic stroke of undetermined source), transesophageal echo can be helpful to detect intracardiac shunts like patent foramen ovale (PFO) or intracardiac tumors. Post stroke care includes secondary prevention measures like risk factor modification and lipid lowering therapy as well as anticoagulation. In high risk for paradoxical embolization, interventional PFO closure can be performed. Interventional closure of the left atrial appendage (LAA) can be discussed in patients with both high thromboembolic and bleeding risk.

Kernaussagen

• Thromboembolien im venösen System können Lungenarterienembolien hervorrufen oder über einen Rechts-links-Shunt paradox ins arterielle Gefäßsystem embolisieren.

• Thromboembolien im arteriellen System haben multiple Ursachen und können arterielle Verschlüsse in jedem Organsystem verursachen.

• Die Therapie der akuten Lungenarterienembolie richtet sich nach dem frühen Sterbe- und Blutungsrisiko.

• In der Akutphase des Schlaganfalls treten kardiale Komplikationen gehäuft auf. Dieses Stroke-Heart-Syndrom resultiert aus einer neurogenen Dysregulation.

• Bei Verdacht auf einen ischämischen Insult durch eine paradoxe Embolie sollte vor interventionellem PFO-Verschluss ein sorgfältiger Ausschluss von alternativen Schlaganfallursachen erfolgen.

Schlüsselwörter

Lungenembolie - ischämischer Insult - thromboembolische Erkrankungen

Keywords

pulmonary embolism - ischemic stroke - thromboembolic disease

Publication History

Article published online:
07 July 2023

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