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Risikostratifikation und differenzierte Therapiekonzepte auf der Intensivstation bei Patienten mit akuter Lungenembolie

Risk stratification and therapy concepts for ICU patients with acute pulmonary embolism

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Das kritische Ereignis in der Pathophysiologie der akuten Lungenembolie ist das Ausmaß der durch die Pulmonalwiderstandserhöhung bedingten rechtsventrikulären Dysfunktion, in dessen Folge es bedingt durch den erhöhten Sauerstoffbedarf, der induzierten myokar dialen Ischämie und der verminderten linksventrikulären Vorlast zu einem Abfall des Herzminutenvolumens kommen kann und in Folge zur Ausbildung eines kardiogenen Schocks. Diese klinische Situation stellt eine Notfallsituation dar mit einer Mortalität > 50%. Größere kontrollierte Studien zur prognostischen Bedeutung einer fibrinolytischen Therapie bei diesen Hochrisikopatienten liegen nicht vor, jedoch besteht Konsens, dass eine fibrinolytische Therapie die Therapie der Wahl darstellt bei Patienten mit massiver Lungenembolie und hämodynamischer Instabilität, wenn nicht absolute Kontraindikationen gegen eine solche Therapie vorliegen. In diesem Fall oder wenn unter der fibrinolytischen Therapie keine hämodynamische Stabilisierung möglich ist, stellen operative Embolektomie oder die kathetergestützte Thrombusfragmentation bzw. Thrombusaspiration gegebenenfalls in Kombination mit einer lokalen Thrombolyse eine therapeutische Alternative dar, auch wenn nur wenige Daten zu ihrer Effektivität und Sicherheit zugrunde gelegt werden können. Hingegen wird kontrovers diskutiert, inwieweit hämodynamisch stabile Patienten mit einer akuten Rechtsherzbelastung von einer thrombolytischen Therapie im Vergleich zu einer alleinigen Heparintherapie profitieren. Zwar steigen mit dem Nachweis der Rechtsherzbelastung auch beim hämodynamisch stabilen Patienten das Mortalitäts- als auch das Komplikationsrisiko, es stellt sich jedoch die Frage, ob dieses Risiko durch eine fibrinolytische Therapie gesenkt werden kann. Inwieweit durch die Kombination des Nachweises der Rechtsherzbelastung in der Bildgebung (Echokardiographie, Computertomographie) und der kardialen Biomarker Troponin T/I oder natriuretische Peptide Brain Natriuretic Peptide (BNP) und N-terminal-proBNP als Hinweis auf eine myokardiale Schädigung diejenigen Patienten zuverlässiger erfasst werden können, die im Hinblick auf eine Verbesserung der Prognose von einer thrombolytischen Therapie profitieren, ist Gegenstand derzeit laufender und zukünftiger Studien.

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Authors and Affiliations

  1. Kardiologie und Angiologie, Universitätsklinikum Freiburg Innere Medizin III, Hugstetterstr. 55, 79106, Freiburg, Germany

    Prof. Dr. Annette Geibel & Prof. Dr. Christoph Bode

  2. Abteilung Kardiologie und Pneumologie, Georg-August-Universität Göttingen Zentrum Innere Medizin, Robert-Koch-Str. 40, 37099, Göttingen, Germany

    Prof. Dr. Stavros Konstantinides

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  1. Prof. Dr. Annette Geibel
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  2. Prof. Dr. Christoph Bode
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  3. Prof. Dr. Stavros Konstantinides
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  1. Medizinische Klinik II Marienhospital Herne, Klinikum der Ruhr-Universität Bochum, Hölkeskampring 40, 44625, Herne

    Hans-Joachim Trappe

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Geibel, A., Bode, C., Konstantinides, S. (2008). Risikostratifikation und differenzierte Therapiekonzepte auf der Intensivstation bei Patienten mit akuter Lungenembolie. In: Trappe, HJ. (eds) Neues aus Kardiologie und Rhythmologie. Steinkopff. https://doi.org/10.1007/978-3-7985-1886-5_9

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