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Hamostaseologie 2018; 38(02): 75-86
DOI: 10.1055/s-0038-1641605
Review Article
Schattauer GmbH Stuttgart

Initial and Long-Term Treatment of Pulmonary Embolism: Current Approach and Future Perspectives

Marco P. Donadini
1   Short Medical Stay Unit and Thrombosis Center, Department of Clinical Medicine, Ospedale di Circolo e Fondazione Macchi, Azienda Socio Sanitaria Territoriale dei Sette Laghi, Varese, Italy
,
Walter Ageno
1   Short Medical Stay Unit and Thrombosis Center, Department of Clinical Medicine, Ospedale di Circolo e Fondazione Macchi, Azienda Socio Sanitaria Territoriale dei Sette Laghi, Varese, Italy
2   Research Center on Thromboembolic Diseases and Antithrombotic Treatment, Department of Medicine and Surgery, University of Insubria, Varese, Italy
› Author Affiliations
Further Information

Publication History

14 July 2017

11 December 2017

Publication Date:
29 May 2018 (online)

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Abstract

Pulmonary embolism is associated with variable risk of early mortality, ranging from less than 1% to more than 15%. Risk stratification, based on clinical variables and signs of right ventricular dysfunction, is crucial to decide the best management and treatment strategy. Home therapy may be an option for low-risk patients, whereas patients at intermediate risk need to be hospitalized and some of them, at intermediate high risk, may require more intensive monitoring to early detect signs of haemodynamic decompensation. The initial treatment is based on anticoagulants with rapid onset of action, either parenteral (heparin/fondaparinux) or oral (direct oral anticoagulants, DOACs). Thereafter, DOACs (or, if contraindicated, vitamin K antagonists) needs to be continued for at least 3 months. Beyond this period, an individual re-evaluation of the risk-to-benefit ratio of anticoagulation should be performed, based on several factors, including the type of index event, age, sex, D-dimer and residual venous obstruction. Possibly safer strategies can be offered to higher risk patients requiring extended duration of treatment, including the DOACs apixaban and rivaroxaban at reduced dose.

Zusammenfassung

Bei Lungenembolien besteht ein variables, zwischen unter 1 % und mehr als 15 % liegendes Risiko der Frühmortalität. Für die Entscheidung über das beste Management und die Behandlungsstrategie ist eine Risikostratifizierung auf Grundlage der klinischen Parameter und der rechtsventrikulären Dysfunktion unabdingbar. Für Patienten mit niedrigem Risiko kann eine Heimtherapie in Frage kommen, während Patienten mit mittlerem Risiko stationär behandelt werden müssen; bei einem höheren bis hohen Risiko ist eventuell eine intensivere Überwachung nötig, um Anzeichen für eine hämodynamische Dekompensation frühzeitig aufzudecken. Die Anfangsbehandlung besteht aus Antikoagulantien mit raschem Wirkungseintritt, entweder parenteral (Heparin/Fondaparinux) oder oral (direkte orale Antikoagulantien, DOAKs). Anschließend sind für mindestens 3 Monate DOAKs (oder, wenn kontraindiziert, Vitamin K- Antagonisten) zu verabreichen. Danach sollte, auf der Basis verschiedener Faktoren, wie Art des Index-Ereignisses, Alter, Geschlecht, D-Dimer und venöse thrombotische Residuen, eine individuelle Neubewertung des Nutzen-/Risikoverhältnisses der Antikoagulation erfolgen. Hochrisikopatienten, die eine längere Therapiedauer benötigen, kann man potenziell sicherere Alternativen anbieten, z. B. die DOAKs Apixaban und Rivaroxaban in geringerer Dosis.

Keywords

pulmonary embolism - risk stratification - direct oral anticoagulants - extended therapy

Schlüsselwörter

Lungenembolie - Risikostratifizierung - Direkte orale Antikoagulanzien - Dauertherapie
 

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