ZNAČAJ KRVARENJA U TOKU LEČENJA AKUTNE TROMBOEMBOLIJE PLUĆA

Bojana Subotić Atanasković; Slobodan  Obradović

doi:10.5937/mp75-46569

Bojana Subotić Atanasković Vojnomedicinska akademija, Crnotravska 17, Beograd
Slobodan Obradović Vojnomedicinska akademija, Crnotravska 17, Beograd

DOI: https://doi.org/10.5937/mp75-46569

Ključne reči: plućna tromboembolija, krvarenje, skor, smanjenje rizika

Sažetak

Antikoagulantna terapija čini osnov lečenja svih bolesnika sa tromboembolijom pluća (PTE), koja se primenjuje već pri sumnji da se radi o PTE, i traje najmanje tri meseca. Kod bolesnika sa najtežim stepenom hemodinamskog opterećenja indikovana je i istovremena primena reperfuzione, najčešće sistemske trombolitičke terapije u inicijalnom lečenju u cilju brze reperfuzije pluća i smanjenja opterećenja desnog srca što smanjuje mortalitet. Obe vrste terapije nose povišen rizik za krvarenje, koje povećava morbiditet, utiče na modifikaciju toka lečenja, a može biti i fatalno. Zbog toga je pre odluke o izboru terapije potrebno proceniti individualni rizik za ovu komplikaciju, i primeniti mere kojima se taj rizik može smanjiti. Osim pojedinačnih faktora rizika za krvarenje, iz populacija bolesnika sa PTE izvedeni su i prediktivni modeli koji mogu pomoći u odlučivanju o načinu lečenja. U grupi bolesnika lečenih trombolizom formiran je PEBSI skor, koji razdvaja rizik za krvarenje u dve kategorije, ali skor još zahteva eksternu validaciju. Za procenu rizika od krvarenja na stabilnoj oralnoj antikoagulantnoj terapiji visoku prediktivnu vrednost i pri eksternoj validaciji pokazao je VTE-BLEED skor. U cilju smanjenja rizika za krvarenje prednost treba dati lekovima novije generacije (aktivator tkivnog plazminogena (tPA) ) u odnosu na strepokinazu i urokinazu; niskomolekularne heparine (LMWH) i fondaparinuks u odnosu na nefrakcionisani heparin (UFH); direktne oralne antikoagulanetne lekove u odnosu na vitamin K antagoniste, potrebno je prilagođavanje doze lekova bubrežnoj funkciji, kao i vrednostima laboratorijskih pokazatelja njihove aktivnosti (aktivirano parcijalno tromboplastinsko vreme za UFH i INR za VKA), a ostaje nedovoljno jasno da li smanjenje doze trombolitičkih lekova ima bolji bezbednosni profil u odnosu na pune terapijske doze. Kod bolesnika sa visokim rizikom za krvarenje, a istovremenom potrebom za agresivnim načinom lečenja, treba razmotriti i nefarmakološko lečenje kao što su hirurška trombektomija ili perkutane kateterske intervencije, mada ove metode nisu dostupne u velikom broju zdravstvenih centara.

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