Thrombose, Lungenembolie und Antikoagulation

Zusammenfassung

Häufigste Ursache einer Lungenarterienembolie (LAE) ist eine venöse Thromboembolie in Folge einer tiefen Beinvenenthrombose (TBVT). Entsprechend der aktuellen Leitlinien, ist bei TVBT oder LAE eine Antikoagulation für mindestens 3 Monate indiziert. In der initialen Phase nach Diagnosestellung kommen hierfür weiterhin hauptsächlich Heparine zum Einsatz. In der Sekundärprävention werden Vitamin-K-Antagonisten (VKA) zunehmend durch die Nicht-Vitamin-K-Antagonisten oralen Antikoagulanzien (NOAK) abgelöst. Vorteilhafte Eigenschaften der NOAKs im Vergleich zu VKA sind insbesondere das günstigere Sicherheitsprofil bezüglich Blutungsereignisse aber auch eine weniger variable Pharmakokinetik und der schnelle Wirkungseintritt. Ob nach der akuten Phase zur Prävention eines Rezidivs die Dauer der Antikoagulation verlängert werden soll, ist vor dem Hintergrund des individuellen Rezidiv- und Blutungsrisikos abzuwägen.

• Literatur

• 1 Konstantinides SV. 2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J 2014; 35: 3145-3146
• 2 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
• 3 Meyer G, Vicaut E, Danays T. et al. Fibrinolysis for patients with intermediate-risk pulmonary embolism. N Engl J Med 2014; 370: 1402-1411
• 4 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: a randomized, multicenter, controlled trial. Chest 2010; 137: 254-262
• 5 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
• 6 EINSTEIN Investigators. Bauersachs R, Berkowitz SD, Brenner B. et al. Oral rivaroxaban for symptomatic venous thromboembolism. N Engl J Med 2010; 363: 2499-2510
• 7 EINSTEIN–PE Investigators. Büller HR, Prins MH, Lensin AW. et al. Oral rivaroxaban for the treatment of symptomatic pulmonary embolism. N Engl J Med 2012; 366: 1287-1297
• 8 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
• 9 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
• 10 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
• 11 Hokusai-VTE Investigators. Büller HR, Décousus H, Grosso MA. et al. Edoxaban versus warfarin for the treatment of symptomatic venous thromboembolism. N Engl J Med 2013; 369: 1406-1415
• 12 Kearon C, Akl EA, Ornelas J. et al. Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report. Chest 2016; 149: 315-352
• 13 Agnelli G, Prandoni P, Santamaria MG. et al. Three months versus one year of oral anticoagulant therapy for idiopathic deep venous thrombosis. Warfarin Optimal Duration Italian Trial Investigators. N Engl J Med 2001; 345: 165-169
• 14 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
• 15 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: 31-40
• 16 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
• 17 Kyrle PA, Rosendaal FR, Eichinger S. Risk assessment for recurrent venous thrombosis. Lancet 2010; 376: 2032-2039
• 18 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
• 19 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
• 20 Weitz JI, Lensing AWA, Prins MH. et al. Rivaroxaban or Aspirin for Extended Treatment of Venous Thromboembolism. N Engl J Med 2017; 376: 1211-1222
• 21 Becattini C, Agnelli G, Schenone A. et al. Aspirin for preventing the recurrence of venous thromboembolism. N Engl J Med 2012; 366: 1959-1967
• 22 Brighton TA, Eikelboom JW, Mann K. et al. Low-dose aspirin for preventing recurrent venous thromboembolism. N Engl J Med 2012; 367: 1979-1987
• 23 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
• 24 Agnelli G, Buller HR, Cohen A. et al. Apixaban for extended treatment of venous thromboembolism. N Engl J Med 2013; 368: 699-708
• 25 Aujesky D, Roy PM, Verschuren F. et al. Outpatient versus inpatient treatment for patients with acute pulmonary embolism: an international, open-label, randomised, non-inferiority trial. Lancet 2011; 378: 41-48
• 26 Zondag W, Kooiman J, Klok FA. et al. Outpatient versus inpatient treatment in patients with pulmonary embolism: a meta-analysis. Eur Respir J 2013; 42: 134-144
• 27 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
• 28 Sallah S, Wan JY, Nguyen NP. Venous thrombosis in patients with solid tumors: determination of frequency and characteristics. Thromb Haemost 2002; 87: 575-579
• 29 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: 677-686
• 30 van der Hulle T, Huisman MV, Klok FA. 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
• 31 Vedovati MC, Germini F, Agnelli G. et al. Direct oral anticoagulants in patients with VTE and cancer: a systematic review and meta-analysis. Chest 2015; 147: 475-483
• 32 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
• 33 Raskob GE, van Es N, Verhamme P. et al. Hokusai VTE Cancer Investigators. Edoxaban for the Treatment of Cancer-Associated Venous Thromboembolism. N Engl J Med 2018; 378: 615-624