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Strategien zur Antikoagulation bei Patienten mit tiefer Beinvenenthrombose und Lungenarterienembolie

Anticoagulation strategies in patients with deep vein thrombosis and pulmonary artery embolisms

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Zusammenfassung

Aufgrund ihrer verwandten Pathophysiologie werden die tiefe Beinvenenthrombose sowie die Lungenarterienembolie unter dem Begriff „venöse Thrombembolien“ (VTE) zusammengefasst. Während die Inzidenz dieser Erkrankungen durch den demographischen Wandel sowie die verbesserte Diagnostik seit Jahren zunimmt, sinken Morbidität und Mortalität. Dies ist v. a. Folge sensitiverer Diagnostik, verbesserter Risikostratifizierung sowie effektiverer Strategien zur Antikoagulation, deren Ziel die Verhinderung früher Ereignisse bis hin zum Tod sowie die Prävention von Rezidiven darstellt. Die Antikoagulationstherapie sollte entweder zunächst mit Heparinen (unfraktioniert oder niedermolekular), Fondaparinux oder auch direkten oralen Antikoagulanzien begonnen werden. Patienten mit einem Rezidivereignis qualifizieren sich für eine dauerhafte Antikoagulation. Bei einem Erstereignis sollte die Antikoagulationstherapie für mindestens 3 Monate erfolgen (Erhaltungstherapie). Nachfolgend kann in Abhängigkeit vom individuellen Risiko (Rezidiv, Blutung) eine verlängerte Erhaltungstherapie im Sinne der Sekundärprävention sinnvoll sein. Hierzu sind mittlerweile auch Nicht-Vitamin-K-abhängige Antikoagulanzien (NOAK) zugelassen. Aufgrund des wahrscheinlich dauerhaft hohen Rezidivrisikos von bis zu 10 % pro Jahr nach Absetzen der Antikoagulation, unzureichender Scores zur Abschätzung des Blutungsrisikos sowie vielversprechender Sicherheitsprofile von NOAK in der Sekundärprävention ist zukünftig von einer Zunahme länger (>3–6 Monate) bis dauerhaft (>1 Jahr) antikoagulierter Patienten nach thromboembolischen Erkrankungen auszugehen.

Abstract

Deep vein thrombosis and pulmonary artery embolisms share pathophysiological features and are therefore collectively referred to as venous thromboembolisms (VTE). While the incidence of VTE has been increasing for years as a result of demographic changes and improved diagnostics, the morbidity and mortality are decreasing. This is particularly due to more sensitive diagnostics, improvements in risk stratification and more effective anticoagulation strategies. The aim of effective anticoagulation therapy is the avoidance of early events up to death and prevention of recurrent events. Anticoagulation treatment should be started with either heparins (unfractionated or low molecular weight), the pentasaccharide fondaparinux or direct oral anticoagulants. Patients with recurrent events qualify for indefinite anticoagulation treatment. For a first episode of VTE anticoagulation treatment for at least 3 months is recommended (maintenance therapy). Subsequently, prolonged maintenance therapy for secondary prevention can be meaningful, depending on the individual patient risk (provoked event, risk for recurrence or bleeding). The non-vitamin K antagonist oral anticoagulants (NOACs) have now also been approved for this indication. As a result of a probably permanently high risk for recurrent events of up to 10% per year after cessation of anticoagulation, insufficient scores for estimation of the risk of bleeding and recent data documenting the safety and efficacy of NOACs for secondary prevention, a shift towards prolonged anticoagulation of 3–6 months or even indefinite (>1 year) treatment can be anticipated for patients after thromboembolic diseases.

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Authors and Affiliations

  1. Klinik für Innere Medizin & Kardiologie, Schön Klinik Neustadt, Am Kiebitzberg 10, 23730, Neustadt in Holstein, Deutschland

    P. W. Radke

  2. Charité Centrum 11 und Notfall‑/Akutmedizin, Chest Pain Units, Charité – Universitätsmedizin Berlin, Berlin, Deutschland

    M. Möckel

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Correspondence to P. W. Radke.

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Interessenkonflikt

P.W. Radke und M. Möckel haben Honorare für Vorträge und Beratungsleistungen von den Firmen Bayer Healthcare, Boehringer Ingelheim, Bristol-Myers Squibb und Daiichi-Sankyo erhalten.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

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Radke, P.W., Möckel, M. Strategien zur Antikoagulation bei Patienten mit tiefer Beinvenenthrombose und Lungenarterienembolie. Herz 43, 34–42 (2018). https://doi.org/10.1007/s00059-017-4655-1

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