cardioКардиологияKardiologiia0022-90402412-5660Kardiomag10.18087/cardio.2019.2.10232cardio-511Research ArticleПРАКТИЧЕСКАЯ КАРДИОЛОГИЯ. ПРИЛОЖЕНИЕ ДЛЯ ПРАКТИЧЕСКИХ ВРАЧЕЙ. КЛИНИЧЕСКИЕ НАБЛЮДЕНИЯPRACTICAL CARDIOLOGY. SUPPLEMENT FOR PRACTISING PHYSICIANS. CASE REPORTВыбор лечебной тактики при тромбоэмболии легочной артерии средневысокого риска и хронической болезни почекThe Choice of Treatment Tactics for Thromboembolism of the Pulmonary Artery of Medium-High Risk and Chronic Kidney DiseaseКомаровА. Л.KomarovA. L.

Москва.

Moscow.

andrkomarov@mail.ru«Институт клинической кардиологии им. А. Л. Мясникова» ФГБУ «Национальный медицинский исследовательский центр кардиологии» Минздрава России.РоссияInstitute of Clinical Cardiology named after A. L. Myasnikov of National Cardiology Research Center.Russian Federation2019080320195928896Copyright © Kardiomag, 20192019KardiomagKardiomaghttps://cardio.elpub.ru/jour/about/submissions#copyrightNoticehttps://cardio.elpub.ru/jour/article/view/511

Представлен клинический разбор пожилого больного с тромбоэмболией легочной артерии средневысокого риска и хронической болезнью почек. Даны рекомендации по современным принципам диагностики, выбора лечебной тактики у больных с данной патологией. Большое внимание уделено вопросам безопасности антикоагулянтного лечения.

A clinical analysis of an elderly patient with medium-high-risk pulmonary thromboembolism and chronic kidney disease is presented. Recommendations on modern principles of diagnosis, choice of treatment tactics in patients with this pathology are given. Much attention is paid to the safety of anticoagulant treatment.

венозные тромбоэмболические осложнениятромбоэмболия легочной артерииантикоагулянтное лечениехроническая болезнь почекvenous thromboembolic complicationspulmonary thromboembolismanticoagulant treatmentchronic kidney diseaseReferencesCohen A.T., Agnelli G., Anderson F.A. et al.; VTE Impact Assessment Group in Europe (VITAE). The number of VTE events and associated morbidity and mortality. Thromb Haemost 2007;98:756–764.Cohen A.T., Agnelli G., Anderson F.A. et al.; VTE Impact Assessment Group in Europe (VITAE). The number of VTE events and associated morbidity and mortality. Thromb Haemost 2007;98:756–764.Heit J.A., Venous thromboembolism: disease burden, outcomes and risk factors. J Thromb Haemost 2005 Aug;3(8):1611-7.Heit J.A., Venous thromboembolism: disease burden, outcomes and risk factors. J Thromb Haemost 2005 Aug;3(8):1611-7.Levey A.S., Stevens L.A., Schmid C.H. et al.; CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration). A new equation to estimate glomerular filtration rate. Ann Intern Med 2009;150:604–612.Levey A.S., Stevens L.A., Schmid C.H. et al.; CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration). A new equation to estimate glomerular filtration rate. Ann Intern Med 2009;150:604–612.Monreal M., Falgá C., Valle R. et al.; RIETE Investigators. Venous thromboembolism in patients with renal insufficiency: findings from the RIETE Registry. Am J Med 2006;119(12):1073–1079. DOI: 10.1016/j.amjmed.2006.04.028.Monreal M., Falgá C., Valle R. et al.; RIETE Investigators. Venous thromboembolism in patients with renal insufficiency: findings from the RIETE Registry. Am J Med 2006;119(12):1073–1079. DOI: 10.1016/j.amjmed.2006.04.028.Böttger B., Wehling M., Bauersachs R.M. et al. Prevalence of renal insufficiency in hospitalised patients with venous thromboembolic events: a retrospective analysis based on 6,725 VTE patients. Thromb Res 2014;134(5):1014–1019. DOI: 10.1016/j.thromres.2014.09.003.Böttger B., Wehling M., Bauersachs R.M. et al. Prevalence of renal insufficiency in hospitalised patients with venous thromboembolic events: a retrospective analysis based on 6,725 VTE patients. Thromb Res 2014;134(5):1014–1019. DOI: 10.1016/j.thromres.2014.09.003.Bauersachs R.M., Lensing A.W., Prins M.H. et al.. Rivaroxaban versus enoxaparin/vitamin K antagonist therapy in patients with venous thromboembolism and renal impairment. Thromb J 2014;12:25. DOI: 10.1186/1477-9560-12-25.Bauersachs R.M., Lensing A.W., Prins M.H. et al.. Rivaroxaban versus enoxaparin/vitamin K antagonist therapy in patients with venous thromboembolism and renal impairment. Thromb J 2014;12:25. DOI: 10.1186/1477-9560-12-25.Steffel J., Verhamme P., Potpara T.S. et al., ESC Scientific Document Group. The 2018 European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation. Eur Heart J 2018;39(16):1330–1393. DOI: 10.1093/eurheartj/ehy136.Steffel J., Verhamme P., Potpara T.S. et al., ESC Scientific Document Group. The 2018 European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation. Eur Heart J 2018;39(16):1330–1393. DOI: 10.1093/eurheartj/ehy136.2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J 2014 Nov 14; 35(43):3033-69. DOI: 10.1093/eurheartj/ehu283.2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J 2014 Nov 14; 35(43):3033-69. DOI: 10.1093/eurheartj/ehu283.Antithrombotic Therapy for VTE Disease. CHEST Guideline and Expert Panel Report. Chest 2016;149(2):315–352.Antithrombotic Therapy for VTE Disease. CHEST Guideline and Expert Panel Report. Chest 2016;149(2):315–352.Management of Massive and Submassive Pulmonary Embolism, Iliofemoral Deep Vein Thrombosis, and Chronic Thromboembolic Pulmonary Hypertension. A Scientific Statement From the American Heart Association. Circulation 2011;123:1788–1830.Management of Massive and Submassive Pulmonary Embolism, Iliofemoral Deep Vein Thrombosis, and Chronic Thromboembolic Pulmonary Hypertension. A Scientific Statement From the American Heart Association. Circulation 2011;123:1788–1830.Engelberger R.P., Kucher N. Ultrasound-assisted thrombolysis for acute pulmonary embolism: a systematic review. Eur Heart J 2014;35(12):758–764. DOI: 10.1093/eurheartj/ehu029.Engelberger R.P., Kucher N. Ultrasound-assisted thrombolysis for acute pulmonary embolism: a systematic review. Eur Heart J 2014;35(12):758–764. DOI: 10.1093/eurheartj/ehu029.Stein P.D., Matta F. Thrombolytic therapy in unstable patients with acute pulmonary embolism: saves lives but underused. Am J Med 2012;125(5):465–470. DOI: 10.1016/j.amjmed.2011.10.015.Stein P.D., Matta F. Thrombolytic therapy in unstable patients with acute pulmonary embolism: saves lives but underused. Am J Med 2012;125(5):465–470. DOI: 10.1016/j.amjmed.2011.10.015.Jiménez D., de Miguel-Díez J., Guijarro R. et al.; RIETE Investigators. Trends in the Management and Outcomes of Acute Pulmonary Embolism: Analysis From the RIETE Registry. J Am Coll Cardiol 2016;67(2):162–170. DOI: 10.1016/j.jacc.2015.10.060.Jiménez D., de Miguel-Díez J., Guijarro R. et al.; RIETE Investigators. Trends in the Management and Outcomes of Acute Pulmonary Embolism: Analysis From the RIETE Registry. J Am Coll Cardiol 2016;67(2):162–170. DOI: 10.1016/j.jacc.2015.10.060.Kline J.A., Steuerwald M.T., Marchick M.R. et al. Prospective evaluation of right ventricular function and functional status 6 months after acute submassive pulmonary embolism: frequency of persistent or subsequent elevation in estimated pulmonary artery pressure. Chest 2009;136(5):1202–1210. DOI: 10.1378/chest.08-2988.Kline J.A., Steuerwald M.T., Marchick M.R. et al. Prospective evaluation of right ventricular function and functional status 6 months after acute submassive pulmonary embolism: frequency of persistent or subsequent elevation in estimated pulmonary artery pressure. Chest 2009;136(5):1202–1210. DOI: 10.1378/chest.08-2988.Meyer G., Vicaut E., Danays T. et al. for PEITHO Investigators. Fibrinolysis for patients with intermediate-risk pulmonary embolism. N Engl J Med 2014;370(15):1402–1411. DOI: 10.1056/NEJMoa1302097.Meyer G., Vicaut E., Danays T. et al. for PEITHO Investigators. Fibrinolysis for patients with intermediate-risk pulmonary embolism. N Engl J Med 2014;370(15):1402–1411. DOI: 10.1056/NEJMoa1302097.Konstantinides S.V., Vicaut E., Danays T. et al. Impact of Thrombo lytic Therapy on the Long-Term Outcome of Inter mediate-Risk Pulmonary Embolism. J Am Coll Cardiol 2017;69(12):1536–1544. DOI: 10.1016/j.jacc.2016.12.039.Konstantinides S.V., Vicaut E., Danays T. et al. Impact of Thrombo lytic Therapy on the Long-Term Outcome of Inter mediate-Risk Pulmonary Embolism. J Am Coll Cardiol 2017;69(12):1536–1544. DOI: 10.1016/j.jacc.2016.12.039.Chatterjee S., Chakraborty A., Weinberg I. et al. Thrombolysis for pulmonary embolism and risk of all-cause mortality, major bleeding, and intracranial hemorrhage: a meta-analysis. JAMA 2014;311(23):2414–2421. DOI: 10.1001/jama.2014.5990.Chatterjee S., Chakraborty A., Weinberg I. et al. Thrombolysis for pulmonary embolism and risk of all-cause mortality, major bleeding, and intracranial hemorrhage: a meta-analysis. JAMA 2014;311(23):2414–2421. DOI: 10.1001/jama.2014.5990.Geldhof V., Vandenbriele C., Verhamme P., Vanassche T. Venous thromboembolism in the elderly: efficacy and safety of non-VKA oral anticoagulants. Thromb J 2014;12:21. DOI: 10.1186/1477-9560-12-21.Geldhof V., Vandenbriele C., Verhamme P., Vanassche T. Venous thromboembolism in the elderly: efficacy and safety of non-VKA oral anticoagulants. Thromb J 2014;12:21. DOI: 10.1186/1477-9560-12-21.Rockwood K, Stadnyk K, MacKnight C, McDowell I, Hebert R, Hogan DB. A brief clinical instrument to classify frailty in elderly people. Lancet 1999;353:205–206.Rockwood K, Stadnyk K, MacKnight C, McDowell I, Hebert R, Hogan DB. A brief clinical instrument to classify frailty in elderly people. Lancet 1999;353:205–206.Tkacheva O.N., Runikhina N.K., Vorobiova N.M. et al. Antithrom bo tic therapy in elderly and senile age: an expert consensus. Cardiovascular Therapy and Prevention. 2017;16(3):4-33. https://doi.org/10.15829/1728-8800-2017-3-4-33 Russian (Ткачева О.Н., Рунихина Н.К., Воробьева Н.М. и др. Антитромбо тическая терапия в пожилом и старческом возрасте: согласованное мне-ние экспертов. Кардиоваскулярная терапия и профилактика 2017;16(3):4–33.)Tkacheva O.N., Runikhina N.K., Vorobiova N.M. et al. Antithrom bo tic therapy in elderly and senile age: an expert consensus. Cardiovascular Therapy and Prevention. 2017;16(3):4-33. https://doi.org/10.15829/1728-8800-2017-3-4-33 Russian (Ткачева О.Н., Рунихина Н.К., Воробьева Н.М. и др. Антитромбо тическая терапия в пожилом и старческом возрасте: согласованное мне-ние экспертов. Кардиоваскулярная терапия и профилактика 2017;16(3):4–33.)Wang Y., Wang C., Chen Z. et al.; Chinese EINSTEIN Investigators. Rivaroxaban for the treatment of symptomatic deep-vein thrombosis and pulmonary embolism in Chinese patients: a subgroup analysis of the EINSTEIN DVT and PE studies. Thromb J 2013;11(1):25. DOI: 10.1186/1477-9560-11-25.Wang Y., Wang C., Chen Z. et al.; Chinese EINSTEIN Investigators. Rivaroxaban for the treatment of symptomatic deep-vein thrombosis and pulmonary embolism in Chinese patients: a subgroup analysis of the EINSTEIN DVT and PE studies. Thromb J 2013;11(1):25. DOI: 10.1186/1477-9560-11-25.Moustafa F., Giorgi Pierfranceschi M., Di Micco P. et al.; RIETE Investigators. Clinical outcomes during anticoagulant therapy in fragile patients with venous thromboembolism. Res Pract Thromb Haemost 2017;1(2):172–179. DOI: 10.1002/rth2.12036.Moustafa F., Giorgi Pierfranceschi M., Di Micco P. et al.; RIETE Investigators. Clinical outcomes during anticoagulant therapy in fragile patients with venous thromboembolism. Res Pract Thromb Haemost 2017;1(2):172–179. DOI: 10.1002/rth2.12036.Prins M.H., Lensing A.W., Bauersachs R. et al.; EINSTEIN Investigators. Oral rivaroxaban versus standard therapy for the treatment of symptomatic venous thromboembolism: a pooled analysis of the EINSTEIN-DVT and PE randomized studies. Thromb J 2013;11(1):21. DOI: 10.1186/1477-9560-11-21.Prins M.H., Lensing A.W., Bauersachs R. et al.; EINSTEIN Investigators. Oral rivaroxaban versus standard therapy for the treatment of symptomatic venous thromboembolism: a pooled analysis of the EINSTEIN-DVT and PE randomized studies. Thromb J 2013;11(1):21. DOI: 10.1186/1477-9560-11-21.Oral Rivaroxaban for the Treatment of Symptomatic Pulmonary Embolism. The EINSTEIN-PE Investigators. N Engl J Med 2012;366:1287–1297.Oral Rivaroxaban for the Treatment of Symptomatic Pulmonary Embolism. The EINSTEIN-PE Investigators. N Engl J Med 2012;366:1287–1297.Böhm M., Ezekowitz M.D., Connolly S.J. et al. Changes in Renal Function in Patients With Atrial Fibrillation: An Analysis From the RE-LY Trial. J Am Coll Cardiol 2015;65(23):2481–2493. DOI: 10.1016/j.jacc.2015.03.577.Böhm M., Ezekowitz M.D., Connolly S.J. et al. Changes in Renal Function in Patients With Atrial Fibrillation: An Analysis From the RE-LY Trial. J Am Coll Cardiol 2015;65(23):2481–2493. DOI: 10.1016/j.jacc.2015.03.577.Fordyce C.B., Hellkamp A.S., Lokhnygina Y. et al.; ROCKET AF Steering Committee and Investigators. On-Treatment Outcomes in Patients With Worsening Renal Function With Rivaroxaban Compared With Warfarin: Insights From ROCKET AF. Circulation 2016;134(1):37–47. DOI: 10.1161/CIRCULATIONAHA.116.021890.Fordyce C.B., Hellkamp A.S., Lokhnygina Y. et al.; ROCKET AF Steering Committee and Investigators. On-Treatment Outcomes in Patients With Worsening Renal Function With Rivaroxaban Compared With Warfarin: Insights From ROCKET AF. Circulation 2016;134(1):37–47. DOI: 10.1161/CIRCULATIONAHA.116.021890.Rossijskie klinicheskie rekomendacii po diagnostike, lecheniju i profilaktike venoznyh trombojembolicheskih oslozhnenij. Flebologija 2015;4(2):1–52. Russian (Российские клинические рекоменда-ции по диагностике, лечению и профилактике венозных тром-боэмболических осложнений. Флебология 2015;4(2):1-52.)Rossijskie klinicheskie rekomendacii po diagnostike, lecheniju i profilaktike venoznyh trombojembolicheskih oslozhnenij. Flebologija 2015;4(2):1–52. Russian (Российские клинические рекоменда-ции по диагностике, лечению и профилактике венозных тром-боэмболических осложнений. Флебология 2015;4(2):1-52.)Prins M.H., Lensing A.W.A., Prandoni P. et al. Risk of recurrent venous thromboembolism according to baseline risk factor profiles. Blood Adv 2018;2(7):788–796. DOI: 10.1182/bloodadvances.2018017160.Prins M.H., Lensing A.W.A., Prandoni P. et al. Risk of recurrent venous thromboembolism according to baseline risk factor profiles. Blood Adv 2018;2(7):788–796. DOI: 10.1182/bloodadvances.2018017160.Brighton T.A., Eikelboom J.W., Mann K. et al. Low-dose aspirin for preventing recurrent venous thromboembolism. N Engl J Med 2012; 367:1979–1987.Brighton T.A., Eikelboom J.W., Mann K. et al. Low-dose aspirin for preventing recurrent venous thromboembolism. N Engl J Med 2012; 367:1979–1987.Becattini C., Agnelli G., Schenone A. et al. Aspirin for preventing the recurrence of venous thromboembolism. N Engl J Med 2012;366:1959–1967.Becattini C., Agnelli G., Schenone A. et al. Aspirin for preventing the recurrence of venous thromboembolism. N Engl J Med 2012;366:1959–1967.Weitz JI, Lensing AWA, Prins MH, et al for EINSTEIN CHOICE Investigators. N Engl J Med 2017 Mar 30;376(13):1211–1222. DOI: 10.1056/NEJMoa1700518.Weitz JI, Lensing AWA, Prins MH, et al for EINSTEIN CHOICE Investigators. N Engl J Med 2017 Mar 30;376(13):1211–1222. DOI: 10.1056/NEJMoa1700518.Palareti G., Cosmi B., Legnani C. et al. D-dimer testing to determine the duration of anticoagulation therapy. N Engl J Med 2006;355(17):1780–1789.Palareti G., Cosmi B., Legnani C. et al. D-dimer testing to determine the duration of anticoagulation therapy. N Engl J Med 2006;355(17):1780–1789.Palareti G., Cosmi B., Legnani C. et al. D-dimer to guide the duration of anticoagulation in patients with venous thromboembolism: a management study. Blood 2014;124(2):196–203.Palareti G., Cosmi B., Legnani C. et al. D-dimer to guide the duration of anticoagulation in patients with venous thromboembolism: a management study. Blood 2014;124(2):196–203.

The authors declare that there are no conflicts of interest present.