Aktuelle Diagnostik und Therapie der akuten Lungenembolie

Diagnosing pulmonary embolism (PE) remains a challenge due to the often confusing clinical presentation of the disease. Plasma D-dimer testing with ELISA is increasingly becoming part of the initial diagnostic work up. Due to the high specificity of the assay, a negative test can reliably exclude PE. Importantly, massive PE can be promptly diagnosed or excluded by echocardiography which is a particularly valuable noninvasive method for detection of right ventricular dysfunction at the bedside. High-risk patients can thus be identified and treated immediately without further time-consuming examinations. Confirmation of PE in patients with inconclusive or normal echocardiograms is often based on lung scans, but diagnostic uncertainty is common with this procedure. The popularity of pulmonary angiography is decreasing due to its invasiveness, whereas spiral CT appears to be a promising alternative. Search for (residual) deep vein thrombosis is useful for guiding therapy in stable patients with small pulmonary emboli, since their risk is determined by the potential for PE recurrence. Recent evidence confirmed that right ventricular dysfunction predicts an unfavorable prognosis and might therefore justify thrombolytic treatment of massive PE regardless of systemic hemodynamics. On the other hand, simplified anticoagulation regimens with low-molecular weight heparins have yielded very promising results in stable patients. These diagnostic and therapeutic principles based on cardiovascular risk stratification will hopefully result in a more effective approach to patients with venous thromboembolism in the future.