Lungenembolie

Zusammenfassung

Die akute Lungenembolie ist eine wichtige Differenzialdiagnose bei akuten Thoraxschmerzen. Die klinischen Zeichen sind häufig wenig spezifisch. Dennoch muss die Diagnose und Therapie wie bei anderen kardiovaskulären Notfällen schnell erfolgen, damit Morbidität und Letalität gesenkt werden können. Auch in der neuen (2014) europäischen Leitlinie zur akuten Lungenembolie stehen risikoadaptierte Diagnosealgorithmen und prognoseadaptierte Therapiekonzepte im Vordergrund. Unverändert erfolgt entsprechend der Hämodynamik primär die Unterteilung in eine Hochrisiko-Gruppe (instabiler Patient mit persistierender Hypotension oder Schock) oder in eine Nicht-Hochrisiko-Gruppen (hämodynamisch stabil).

In der Hochrisiko-Gruppe erfolgt die unverzügliche Diagnostik zumeist mittels Multidetektor-Spiral-Computertomografie (MDCT) sowie primär die intensivmedizinische Therapie der rechtsventrikulären Dysfunktion sowie die kausale rekanalisierende Therapie mittels Thrombolyse.

In der Nicht-Hochrisiko-Gruppe, welche in eine intermediär- und eine niedrig Risikogruppe weiter untergliedert wird, orientiert sich der Diagnosealgorithmus an der Lungenembolie-Vortest-Wahrscheinlichkeit – erhoben durch validierte Scores – sowie auch am hohen negativen prädiktiven Wert der D-Dimer-Bestimmung. Die Diagnosesicherung erfolgt zumeist ebenso mittels MDCT als neuer Goldstandard in der Lungenembolie-Diagnostik. Zur weiteren Risikostratifizierung in der Nicht-Hochrisiko-Gruppe wird neben dem Nachweis der rechtsventrikulären Dysfunktion in der Bildgebung (MDCT, Echokardiografie) und dem laborchemischen Nachweis von kardialen Biomarken (Troponin, NT- proBNP) ein validiertes Scoring-System (z. B. Pulmonary Embolism Severity Index) zur weiteren Verbesserung der Prognoseabschätzung aktuell empfohlen. Daher kann insbesondere die Intermediär-Risikogruppe weiter stratifiziert werden. In der Therapie der Nicht-Hochrisiko-Gruppe erfolgt die initiale Antikoagulation (außer bei schwerer Niereninsuffizienz) mittels niedermolekularen Heparin/ Fondaparinux und Umstellung auf Vitamin-K-Antagonisten oder alternativ mit direkten oralen Antikoagulanzien (DOAK). Hämodynamisch stabile Patienten mit rechtsventrikulären Dysfunktion und myokardialer Ischämie (Intermediär-Hoch-Risiko-Gruppe) aber mit klinisch progredienter hämodynamischer Dekompensation können von einer systemischen Lysetherapie profitieren. Aufgrund des hohen Blutungsrisikos in der PEITHO-Studie sollte allerdings eine kritische individuelle Risiko-Nutzenabwägung erfolgen. Die dosisreduzierte systemische oder lokale ultraschallunterstützte Lyseapplikation könnte hierbei zukünftig Bedeutung erlangen. Für ausgewählte Patienten in der Niedrig-Risiko-Gruppe ist eine frühe ambulante Weiterbehandlung zu erwägen.

Die Diagnose und Therapie der Lungenembolie bleibt komplex. Weiter verbesserte Algorithmen unterstützen aber bei der Diagnosestellung und insbesondere Therapieentscheidung. Direkt orale Antikoagulanzien sind eine First-Line-Therapiealternative bei hämodynamisch stabilen Nicht-Hochrisiko-Patienten.

Abstract

Acute pulmonary embolism is an important differential diagnosis of acute chest pain. The clinical signs are often non-specific. However, diagnosis and therapy must be done quickly in order to reduce morbidity and mortality. The new (2014) European guidelines for acute pulmonary embolism (PE) focus on risk-adapted diagnostic algorithms and prognosis adapted therapy concepts. According to the hemodynamic presentation the division in a high-risk group (unstable patient with persistent hypotension or shock) or in non-high-risk groups (hemodynamically stable) was proposed.

In the high-risk group the immediate diagnosis is usually done by multidetector spiral computed tomography (MDCT) and primarily the medical therapy of right ventricular dysfunction and thrombolysis is recommended.

In the non-high-risk group, this is subdivided into an intermediate-risk group and low-risk group, the diagnosis algorithm based on the PE-pretest probability – determined by validated scores. Moreover, the diagnosis is usually secured by MDCT - the new gold standard in the PE-diagnosis, scores, or it can be primarily ruled out due to the high negative predictive value of D-dimer determination. To improve the prognostic risk stratification in non-high-risk group patients the additional detection of right ventricular dysfunction (MDCT, echocardiography), cardiac biomarkers (troponin, NT proBNP) and validated scores (e. g. Pulmonary Embolism Severity Index ) is recommended. Therefore, the intermediate-risk group can be further subdivided. For treatment of non-high-risk group patients, the initial anticoagulation (except those with severe renal insufficiency) using low molecular weight heparin / fondaparinux and conversion to vitamin-K antagonists or alternatively with direct oral anticoagulants (DOAK) is recommended. Hemodynamically stable patients with right ventricular dysfunction and myocardial ischemia (Intermediate-high-risk group patinets) but with clinically progressive hemodynamic decompensation may benefit from systemic thrombolysis as well. Due to the high risk of bleeding in the PEITHO study, however, a critical individual risk-benefit evaluation should be done. A dose reduced systemic or local ultrasound-assisted thrombolysis could gain importance in the future. For very selected patients in the low-risk group early outpatient treatment could be considered.

The diagnosis and treatment of pulmonary embolism remains complex. Improved algorithms support the diagnosis procedures and therapy decisions. Direct oral anticoagulants are a new first-line therapy alternative for hemodynamically stable non-high-risk patients.

Schlüsselwörter

Lungenembolie - akuter Thoraxschmerz - akute rechtsventrikuläre Dysfunktion - Risikostratifizierung - direkte orale Antikoagulanzien - Thrombolyse

Key Words

acute non cardiac chest pain - pulmonary embolism - acute right ventricular dysfunction - risk stratification - direct oral anticoagulants - thrombolysis

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