Hobohm Lukas, Lankeit Mareike
Pneumologie. 2021 Oct;75(10):800-818. doi: 10.1055/a-1029-9937. Epub 2021 Oct 18.
Pulmonary embolism (PE) is a life-threatening disease and the third most frequent cardiovascular cause of death after stroke and myocardial infarction. The annual incidence is increasing (in Germany from 85 cases per 100000 population in the year 2005 to 109 cases per 100000 population in the year 2015). The individual risk for PE-related complications and death increases with the number of comorbidities and severity of right ventricular dysfunction. Using clinical, laboratory and imaging parameters, patients with PE can be stratified to four risk classes (high, intermediate-high, intermediate-low and low risk). This risk stratification has concrete therapeutic consequences ranging from out-of-hospital treatment of low-risk patients to reperfusion treatment of (intermediate)-high-risk patients. For haemodynamically unstable patients, treatment decision should preferably be made in interdisciplinary "Pulmonary Embolism Response Teams" (PERT). Due to their comparable efficacy and preferable safety profile compared to vitamin-K antagonists (VKAs), non-vitamin K-dependent oral anticoagulants (NOACs) are increasingly considered the treatment of choice for initial and prolonged anticoagulation of patients with pulmonary embolism. Use of low molecular weight heparins (LMWHs) is recommended for PE patients with cancer; however, recent studies indicate that treatment with factor Xa-inhibitors may be effective and safe (in patients without gastrointestinal cancer). Only prolonged anticoagulation (in reduced dosage) will ensure reduction of VTE recurrence and should thus be considered for all patients with unprovoked events.
肺栓塞(PE)是一种危及生命的疾病,是继中风和心肌梗死后第三常见的心血管死亡原因。其年发病率呈上升趋势(在德国,从2005年的每10万人85例增至2015年的每10万人109例)。PE相关并发症和死亡的个体风险会随着合并症数量和右心室功能障碍的严重程度而增加。利用临床、实验室和影像学参数,可将PE患者分为四个风险等级(高、中高、中低和低风险)。这种风险分层具有具体的治疗意义,从低风险患者的院外治疗到(中)高风险患者的再灌注治疗不等。对于血流动力学不稳定的患者,治疗决策最好在跨学科的“肺栓塞反应团队”(PERT)中做出。与维生素K拮抗剂(VKA)相比,非维生素K依赖口服抗凝剂(NOAC)具有相当的疗效和更好的安全性,因此越来越被视为肺栓塞患者初始和长期抗凝治疗的首选。对于患有癌症的PE患者,建议使用低分子量肝素(LMWH);然而,最近的研究表明,Xa因子抑制剂治疗可能有效且安全(对于无胃肠道癌症的患者)。只有长期抗凝(降低剂量)才能确保降低VTE复发率,因此所有无诱因事件的患者均应考虑进行长期抗凝治疗。