Lungenembolie: ambulante Therapie und Nachsorge

Trotz sinkender Fallzahlen ist die Lungenembolie nach wie vor eine häufige Todesursache, insbesondere bei älteren Menschen. Im Mittelpunkt der aktuellen Leitlinien stehen die schnelle Risikoeinschätzung bei Verdacht auf eine Lungenembolie sowie die geeignete Therapie. Die Beurteilung, welche Patienten für eine ambulante Behandlung geeignet sind, sowie die passende Nachsorgestrategie werden im Folgenden erörtert.

Abstract

Despite declining numbers – older people in particular – often die from pulmonary embolism. A rapid assessment of the risk in the event of a suspected embolism, the exclusion of comorbidities and the appropriate therapy are the focus of the current guidelines. Early and subsequent outpatient treatment of a patient with acute PE generally requires 3 criteria: low risk of early complications, the absence of serious comorbidities and the highest possible safety at home and, in the event of a complication, rapid access to acute care in the hospital. For patients with a high risk of VTE recurrence, the long-term dosage of secondary drug prophylaxis is not yet clear – studies are currently underway. In patients at moderate risk of VTE recurrence, low-dose secondary prophylaxis can be used to reduce the risk of bleeding. Outpatient pulmonary embolism follow-up care is becoming increasingly important, because studies have shown several times that serious long-term consequences can occur. In pulmonary embolism patients with persistent dyspnea, reduced performance or risk of CTEPH, an outpatient evaluation of the right ventricle using echocardiography, if necessary, in combination with the determination of natriuretic peptides or spiroergometry, is recommended.

Kernaussagen

• Eine frühzeitige und anschließende ambulante Behandlung eines Patienten mit akuter LE erfordert grundsätzlich 3 Kriterien: niedriges Risiko für frühe Komplikationen, das Fehlen schwerer Komorbiditäten und die höchstmögliche Sicherheit zu Hause, und im Falle einer Komplikation schnellen Zugang zur Akutversorgung im Krankenhaus.

• Bei Patienten mit hohem Rezidivrisiko für eine VTE ist die langfristige Dosierung der medikamentösen Sekundärprophylaxe noch nicht abschließend geklärt – derzeitige noch einschließende Studie stehen noch aus.

• Bei Patienten mit moderatem Rezidivrisiko für eine VTE kann eine Sekundärprophylaxe in Niedrigdosis durchgeführt werden, um das Blutungsrisiko zu reduzieren.

• Die ambulante Nachsorge einer Lungenembolie gewinnt an Bedeutung, da mehrfach in Studien gezeigt wurde, dass schwere Langzeitfolgen auftreten können.

• Bei Lungenembolie-Patienten mit persistierender Dyspnoe, Leistungsminderung oder Risiko für eine CTEPH ist eine ambulante Evaluation des rechten Ventrikels mittels Echokardiografie, ggf. in Kombination mit der Bestimmung natriuretischer Peptide oder einer Spiroergometrie, zu empfehlen.

Schlüsselwörter

Lungenembolie - stationäre Behandlung - ambulante Behandlung - Nachsorge - Rezidivrisiko - Antikoagulation

Keywords

pulmonary embolism - inpatient treatment - outpatient treatment - aftercare - risk of recurrence - anticoagulation

Publikationsverlauf

Artikel online veröffentlicht:
23. September 2024

• Literatur

• 1 Raskob GE, Angchaisuksiri P, Blanco AN. et al. Thrombosis: a major contributor to global disease burden. Arterioscler Thromb Vasc Biol 2014; 34 (11) 2363-2371
• 2 Wendelboe AM, Raskob GE. Global Burden of Thrombosis: Epidemiologic Aspects. Circ Res 2016; 118 (09) 1340-1347
• 3 Barco S, Mahmoudpour SH, Valerio L. et al. Trends in mortality related to pulmonary embolism in the European Region, 2000–15: analysis of vital registration data from the WHO Mortality Database. Lancet Respir Med 2020; 8 (03) 277-287
• 4 Keller K, Hobohm L, Ebner M. et al. Trends in thrombolytic treatment and outcomes of acute pulmonary embolism in Germany. Eur Heart J 2020; 41 (04) 522-529
• 5 Konstantinides SV, Meyer G, Becattini C. et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J 2020; 41 (04) 543-603
• 6 Meyer G, Vicaut E, Danays T. et al. Fibrinolysis for patients with intermediate-risk pulmonary embolism. N Engl J Med 2014; 370 (15) 1402-1411
• 7 Tapson VF, Sterling K, Jones N. et al. A Randomized Trial of the Optimum Duration of Acoustic Pulse Thrombolysis Procedure in Acute Intermediate-Risk Pulmonary Embolism: The OPTALYSE PE Trial. JACC Cardiovasc Interv 2018; 11 (14) 1401-1410
• 8 Kucher N, Boekstegers P, Muller OJ. et al. Randomized, controlled trial of ultrasound-assisted catheter-directed thrombolysis for acute intermediate-risk pulmonary embolism. Circulation 2014; 129 (04) 479-486
• 9 den Exter PL, Zondag W, Klok FA. et al. Efficacy and Safety of Outpatient Treatment Based on the Hestia Clinical Decision Rule With or Without NT-proBNP Testing in Patients With Acute Pulmonary Embolism: A Randomized Clinical Trial. Am J Respir Crit Care Med 2016; 194 (08) 998-1006
• 10 Zondag W, Mos IC, Creemers-Schild D. et al. Outpatient treatment in patients with acute pulmonary embolism: the Hestia Study. J Thromb Haemost 2011; 9 (08) 1500-1507
• 11 Barco S, Mahmoudpour SH, Planquette B. et al. Prognostic value of right ventricular dysfunction or elevated cardiac biomarkers in patients with low-risk pulmonary embolism: a systematic review and meta-analysis. Eur Heart J 2019; 40 (11) 902-910
• 12 Barco S, Schmidtmann I, Ageno W. et al. Early Discharge and Home Treatment of Patients with Low-Risk Pulmonary Embolism with the Oral Factor Xa Inhibitor Rivaroxaban. An International Multicentre Single-arm Clinical Trial. Eur Heart J 2020; 41 (04) 509-518
• 13 Agnelli G, Buller HR, Cohen A. et al. Oral apixaban for the treatment of acute venous thromboembolism. N Engl J Med 2013; 369 (09) 799-808
• 14 Buller HR, Prins MH, Lensin AW. et al. Oral rivaroxaban for the treatment of symptomatic pulmonary embolism. N Engl J Med 2012; 366 (14) 1287-1297
• 15 Pengo V, Denas G, Zoppellaro G. et al. Rivaroxaban vs warfarin in high-risk patients with antiphospholipid syndrome. Blood 2018; 132 (13) 1365-1371
• 16 Bauersachs R, Langer F, Kalka C. et al. Treatment of the antiphospholipid syndrome with direct oral anticoagulantsPosition statement of German societies. Vasa 2019; 48 (06) 483-486
• 17 Kearon C, Akl EA, Ornelas J. et al. Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report. Chest 2016; 149 (02) 315-352
• 18 Agnelli G, Prandoni P, Becattini C. et al. Extended oral anticoagulant therapy after a first episode of pulmonary embolism. Ann Intern Med 2003; 139 (01) 19-25
• 19 Iorio A, Kearon C, Filippucci E. et al. Risk of recurrence after a first episode of symptomatic venous thromboembolism provoked by a transient risk factor: a systematic review. Arch Intern Med 2010; 170 (19) 1710-1716
• 20 Baglin T, Luddington R, Brown K. et al. Incidence of recurrent venous thromboembolism in relation to clinical and thrombophilic risk factors: prospective cohort study. Lancet 2003; 362: 523-526
• 21 Schulman S, Granqvist S, Holmstrom M. et al. The duration of oral anticoagulant therapy after a second episode of venous thromboembolism. The Duration of Anticoagulation Trial Study Group. N Engl J Med 1997; 336 (06) 393-398
• 22 Weitz JI, Lensing AWA, Prins MH. et al. Rivaroxaban or Aspirin for Extended Treatment of Venous Thromboembolism. N Engl J Med 2017; 376 (13) 1211-1222
• 23 Agnelli G, Buller HR, Cohen A. et al. Apixaban for extended treatment of venous thromboembolism. N Engl J Med 2013; 368 (08) 699-708
• 24 Khorana AA, Noble S, Lee AYY. et al. Role of direct oral anticoagulants in the treatment of cancer-associated venous thromboembolism: guidance from the SSC of the ISTH. J Thromb Haemost 2018; 16 (09) 1891-1894
• 25 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 (20) 2017-2023
• 26 Raskob GE, van Es N, Verhamme P. et al. Edoxaban for the Treatment of Cancer-Associated Venous Thromboembolism. N Engl J Med 2018; 378 (07) 615-624
• 27 Agnelli G, Becattini C, Bauersachs R. et al. Apixaban versus Dalteparin for the Treatment of Acute Venous Thromboembolism in Patients with Cancer: The Caravaggio Study. Thromb Haemost 2018; 118 (09) 1668-1678
• 28 Linnemann B, Blank W, Doenst T. et al. Diagnostik und Therapie der tiefen Venenthrombose und Lungenembolie – AWMF-S2k-Leitlinie. Stand: 2023. Zugriff am 18. August 2024 unter: https://register.awmf.org/de/leitlinien/detail/065–002
• 29 Valerio L, Mavromanoli AC, Barco S. et al. Chronic thromboembolic pulmonary hypertension and impairment after pulmonary embolism: the FOCUS study. Eur Heart J 2022; 43 (36) 3387-3398
• 30 Humbert M, Kovacs G, Hoeper MM. et al. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Heart J 2022; 43 (38) 3618-3731
• 31 Stevinson BG, Hernandez-Nino J, Rose G. et al. Echocardiographic and functional cardiopulmonary problems 6 months after first-time pulmonary embolism in previously healthy patients. Eur Heart J 2007; 28 (20) 2517-2524
• 32 Kahn SR, Hirsch AM, Akaberi A. et al. Functional and Exercise Limitations After a First Episode of Pulmonary Embolism: Results of the ELOPE Prospective Cohort Study. Chest 2017; 151 (05) 1058-1068
• 33 Dzikowska-Diduch O, Kostrubiec M, Kurnicka K. et al. The post-pulmonary syndrome – results of echocardiographic driven follow up after acute pulmonary embolism. Thromb Res 2020; 186: 30-35
• 34 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 (12) 1536-1544
• 35 Klok FA, van Kralingen KW, van Dijk AP. et al. Prevalence and potential determinants of exertional dyspnea after acute pulmonary embolism. Respir Med 2010; 104 (11) 1744-1749
• 36 Keller K, Tesche C, Gerhold-Ay A. et al. Quality of life and functional limitations after pulmonary embolism and its prognostic relevance. J Thromb Haemost 2019; 17 (11) 1923-1934
• 37 Valerio L, Barco S, Jankowski M. et al. Quality of Life 3 and 12 Months Following Acute Pulmonary Embolism: Analysis From a Prospective Multicenter Cohort Study. Chest 2021; 159 (06) 2428-2438