Antithrombozytäre Therapie und Antikoagulation bei Patienten mit koronarer Herzerkrankung

Die koronare Herzkrankheit (KHK) ist ein dynamischer Prozess mit akuten instabilen Ereignissen und chronischen Perioden, die zu einer erhöhten Mortalität führen. Patienten mit KHK profitieren von einer differenzierten antithrombotischen Therapie. Dieser Artikel bietet Informationen zu den verschiedenen Medikamenten und therapeutischen Algorithmen basierend auf den neuesten ESC-Richtlinien und aktuellen Studien.

Abstract

Coronary heart disease (CHD) is a dynamic process with acute instable events and chronic periods leading to an increased mortality. Patients with CHD benefit from a differentiated antithrombotic therapy consisting of dual antiplatelet therapy in the acute phase and antiplatelet monotherapy or in combination with low dose anticoagulation (Xa-Inhibition) in the chronic phase. Current ESC-guidelines differentiate the acute coronary syndrome (ACS) and the chronic coronary syndrome (CCS). Depending on thrombotic burden, bleeding risk, comorbidities, such as atrial fibrillation, antiplatelet agents and oral anticoagulants in various combinations and dosages are used. In most scenarios in patients with ACS, the initial therapy will consist out of acetylsalicylic acid and a P2Y₁₂-Inhibitor for 12 months followed by either a continuous monotherapy with acetylsalicylic acid (ASS), a prolonged dual antiplatelet therapy or a continuous dual antithrombotic therapy consisting of ASS and low dose rivaroxaban 2x daily. With atrial fibrillation as an underlying condition, an anticoagulant should be part of the therapy followed by anticoagulant monotherapy in the chronic phase of the disease (CCS). This article provides information about the different drugs and therapeutic algorithms based on the newest ESC-Guidelines and up to date studies.

Schlüsselwörter

NSTEMI - antithrombotische Therapie - Antikoagulation - koronare Herzkrankheit - duale Plättchenaggregationshemmung - duale antithrombotische Therapie - chronisches Koronarsyndrom

Key words

non-ST-Elevation myocardial infarction - antithrombotic therapy - anticoagulation - coronary heart disease - dual platelet inhibition - dual antithrombotic therapy - chronic coronary syndrome

Publication History

Article published online:
20 August 2021

• Literatur

• 1 Eikelboom JW, Connolly SJ, Bosch J. et al. Rivaroxaban with or without Aspirin in Stable Cardiovascular Disease. N Engl J Med 2017; 377: 1319-1330 DOI: 10.1056/nejmoa1709118.
• 2 Ahrens I, Bode C. Direct Oral Anticoagulants in Acute Coronary Syndrome. Semin Hematol 2014; 51: 147-151 DOI: 10.1053/j.seminhematol.2014.03.004.
• 3 Ahrens I, Peter K, Bode C. Use of GPIIb/IIIa inhibitors in cardiovascular medicine. Expert Rev Cardiovasc Ther 2003; 1: 233-242 DOI: 10.1586/14779072.1.2.233.
• 4 Collet J-P, Thiele H, Barbato E. et al. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J 2021; 42: 1289-1367 DOI: 10.1093/eurheartj/ehaa575.
• 5 Yeh RW, Secemsky EA, Kereiakes DJ. et al. Development and validation of a prediction rule for benefit and harm of Dual antiplatelet therapy beyond 1 year after percutaneous coronary intervention. JAMA – J Am Med Assoc 2016; 315: 1735-1749 DOI: 10.1001/jama.2016.3775.
• 6 Costa F, van Klaveren D, James S. et al. Derivation and validation of the predicting bleeding complications in patients undergoing stent implantation and subsequent dual antiplatelet therapy (PRECISE-DAPT) score: a pooled analysis of individual-patient datasets from clinical trials. Lancet 2017; 389: 1025-1034 DOI: 10.1016/S0140-6736(17)30397-5.
• 7 Subherwal S, Bach RG, Chen AY. et al. Baseline risk of major bleeding in non-sT-segment- elevation myocardial infarction the CRUSADE (can rapid risk stratification of unstable angina patients suppress ADverse outcomes with early implementation of the ACC/AHA guidelines) bleeding score. Circulation 2009; 119: 1873-1882 DOI: 10.1161/CIRCULATIONAHA.108.828541.
• 8 Mehran R, Baber U, Sharma SK. et al. Ticagrelor with or without Aspirin in High-Risk Patients after PCI. N Engl J Med 2019; 381: 2032-2042 DOI: 10.1056/nejmoa1908419.
• 9 Dewilde WJM, Oirbans T, Verheugt FWA. et al. Use of clopidogrel with or without aspirin in patients taking oral anticoagulant therapy and undergoing percutaneous coronary intervention: An open-label, randomised, controlled trial. Lancet 2013; 381: 1107-1115 DOI: 10.1016/S0140-6736(12)62177-1.
• 10 Gibson CM, Mehran R, Bode C. et al. Prevention of Bleeding in Patients with Atrial Fibrillation Undergoing PCI. N Engl J Med 2016; 375: 2423-2434 DOI: 10.1056/nejmoa1611594.
• 11 Cannon CP, Bhatt DL, Oldgren J. et al. Dual Antithrombotic Therapy with Dabigatran after PCI in Atrial Fibrillation. N Engl J Med 2017; 377: 1513-1524 DOI: 10.1056/nejmoa1708454.
• 12 Vranckx P, Valgimigli M, Eckardt L. et al. Edoxaban-based versus vitamin K antagonist-based antithrombotic regimen after successful coronary stenting in patients with atrial fibrillation (ENTRUST-AF PCI): a randomised, open-label, phase 3b trial. Lancet 2019; 394: 1335-1343 DOI: 10.1016/S0140-6736(19)31872-0.
• 13 Lopes RD, Heizer G, Aronson R. et al. Antithrombotic Therapy after Acute Coronary Syndrome or PCI in Atrial Fibrillation. N Engl J Med 2019; 380: 1509-1524 DOI: 10.1056/nejmoa1817083.
• 14 Bonaca MP, Storey RF, Theroux P. et al. Efficacy and Safety of Ticagrelor Over Time in Patients With Prior MI in PEGASUS-TIMI 54. J Am Coll Cardiol 2017; 70: 1368-1375 DOI: 10.1016/j.jacc.2017.07.768.
• 15 Neumann FJ, Sechtem U, Banning AP. et al. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes. Eur Heart J 2020; 41: 407-477 DOI: 10.1093/eurheartj/ehz425.
• 16 Yasuda S, Kaikita K, Akao M. et al. Antithrombotic Therapy for Atrial Fibrillation with Stable Coronary Disease. N Engl J Med 2019; 381: 1103-1113 DOI: 10.1056/nejmoa1904143.