Sekundärprophylaxe der venösen Thromboembolie

R. Sternitzky; S. Hochauf; S. M. Schellong

doi:10.1055/s-0037-1616897

Hämostaseologie, Table of Contents

Hamostaseologie 2007; 27(01): 32-40
DOI: 10.1055/s-0037-1616897

Orginal Articles

Schattauer GmbH

Sekundärprophylaxe der venösen Thromboembolie

Secondary prophylaxis of venous thromboembolism

Authors

R. Sternitzky

¹Arbeitsbereich Angiologie, Praxisklinik Herz und Gefäße, Uniklinikum, Dresden
S. Hochauf

²Arbeitsbereich Angiologie, Medizinische Klinik und Poliklinik III, Uniklinikum, Dresden
S. M. Schellong

²Arbeitsbereich Angiologie, Medizinische Klinik und Poliklinik III, Uniklinikum, Dresden

Abstract

Zusammenfassung

Der Standard in der Erhaltungstherapie (Sekundärprophylaxe) der venösen Thromboembolie ist die Gabe von Vitamin- K-Antagonisten mit einer Ziel-INR von 2,0 bis 3,0. Die Rezidivrate sinkt hierunter auf ein Minimum von ca. 1% pro Jahr. Allerdings muss in Abhängigkeit vom Patientenprofil mit größeren Blutungen in einer Häufigkeit von 1 bis 3% gerechnet werden. Die Standarddauer der Erhaltungstherapie beträgt 3-6 Monate. Zu diesem Zeitpunkt endet sie in jedem Fall bei Patienten mit einem vorübergehenden Risikofaktor (Operation, Trauma). Die Verlängerung der Erhaltungstherapie kommt nur für Patienten mit erhöhtem Rezidivrisiko in Frage. Bereits nach der ersten Episode kann sie auf unbestimmte Dauer angesetzt werden bei Patienten mit aktiver Krebserkrankung oder schweren thrombophilen Defekten (Antiphospholipidsyndrom, schwerem familiären Antithrombin-, Protein-C- oder Protein-S-Mangel). Zunächst auf ein Jahr befristen wird man die Erhaltungstherapie bei einer ersten idiopathischen Episode von VTE oder mittelschweren (z. B. kombinierten) thrombophilen Defekten. Der einfache heterozygote Faktor-V-Leiden-Defekt oder die Prothrombin-20210-Variante fallen nicht darunter. Das Rezidiv einer idiopathischen Thrombose wiederum sollte Anlass für eine längerfristige oder dauerhafte Erhaltungstherapie sein. Jede Entscheidung über die Dauer muss eine – periodisch wiederholte – Abschätzung des individuellen Blutungsrisikos beinhalten und individuelle Präferenzen des Patienten berücksichtigen. Als alternative Medikation zur Erhaltungstherapie stehen zurzeit niedermolekulare Heparine zur Verfügung. Neue parenterale und oral zu verabreichende Wirkstoffe befinden sich in der klinischen Erprobung.

Summary

Making decisions about any modality of secondary prophylaxis in patients with venous thromobembolism (VTE) has to balance the risk of bleeding induced by anticoagulants against the benefit of reducing the risk of recurrent disease. It has to be kept in mind that the magnitude of risk is not only defined by the number of events per time period but also by the impact of the event on the fate of the patient. With standard intensity vitamin K antagonists (VKA), the risk of bleeding is more closely related to comorbidities than to other factors, eg age. The risk of VTE recurrence differs largely between patient groups. The criterion of presence or absence of a permanent or transient clinical trigger factor for the actual VTE episode has a greater impact than an abnormal result in thrombophilia testing. The standard period of secondary prophylaxis for proximal DVT and for PE is three to six months. The concept of prolonging this period for several months according to the risk of recurrence is seriously challanged by the observation that the prolongation period seems to delay recurrencies rather than truly avoiding them. For this reason, patients who clearly are threatened by recurrent episodes should receive indefinitive secondary prophylaxis. This is the case for cancer patients, patients with the antiphospholipid syndrome, and those who belong to families with severe and symptomatic protein C, protein S, or antithrombin deficiencies. Patients with recurrent VTE, with idiopathic VTE, or with combined thrombophilic conditions may only benefit from indefinitive secondary prophylaxis if the bleeding risk of the anticoagulant regimen under consideration is very low.

Schlüsselwörter

Venöse Thromboembolie - Antikoagulation - Sekundärprophylaxe - Therapie

Keywords

Venous thromboembolism - anticoagulation - therapy of VTE - secondary prophylaxis of VTE

Full Text

References

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