Aktuelles zur Thrombozytenaggregationshemmung

Zusammenfassung

Der ADP-Rezeptor (P2Y₁₂)-Antagonist Clopidogrel hat sich in der Therapie des akuten Koronarsyndroms sowie nach koronarer Stent-Implantation zur dualen Thrombozytenaggregationshemmung neben Aspirin bewährt. Vor allem aufgrund der Metabolisierung in die aktive Form sowie seines irreversiblen Effektes hat Clopidogrel allerdings Nachteile, die seine Effektivität in der Reduktion klinischer Ereignisse beeinflussen könnten. Zwei Neuentwicklungen zur Thrombozytenaggregationshemmung bei akutem Koronarsyndrom könnten anwendungsrelevant werden. Der irreversible ADP-Rezeptor-Antagonist Prasugrel führt zu einer stärkeren Thrombozytenaggregationshemmung als Clopidogrel und zeigte in der TRITON-Studie weniger ischämische, aber mehr Blutungskomplikationen. Der ohne Metabolisierung wirksame, reversible ADP-Rezeptorantagonist Ticagrelor ist ebenfalls potenter als Clopidogrel in der Thrombozytenaggregationshemmung. Ticagrelor zeigte in der PLATO-Studie eine Reduktion ischämischer Ereignisse bei insgesamt nicht mehr schweren Blutungskomplikationen im Vergleich zu Clopidogrel, und führte außerdem zu einer Reduktion der Gesamtmortalität. Diese Übersichtsarbeit stellt bisherige Daten zu den neuen Substanzen zusammen und leitet mögliche Konsequenzen für die klinische Praxis ab.

Abstract

Use of the ADP (P2Y₁₂)-receptor antagonist clopidogrel is a cornerstone of dual platelet inhibition in acute coronary syndromes and following stent implantation. Because of the metabolization into its active form and the irreversible inhibition of the ADP receptor there are disadvantages to clopidogrel which could limit its efficacy in reducing clinical events. This is particularly problematic in so-called poor responders with reduced metabolizing activity and hence reduced platelet inhibition. Two novel drugs for platelet inhibition in acute coronary syndrome could become relevant in clinical practice. The irreversible ADP-receptor antagonist prasugrel led to stronger platelet inhibition, fewer ischemic events but more bleeding complications compared to clopidogrel in the TRITON-TIMI-38 trial. The reversibly binding, direct-acting ADP-receptor antagonist ticagrelor, which is effective without metabolization, is also superior over clopidogrel in reducing platelet aggregation and decreased the number of ischemic events in the PLATO-trial. However, it did not increase the rate of overall major bleeding and was shown to reduce total mortality. This review article summarizes current data on novel platelet inhibitors and delineates their potential influence on clinical practice.

Thrombozytenaggregationshemmung - akutes Koronarsyndrom - perkutane Koronarintervention (PCI) - Ticagrelor - Prasugrel - Clopidogrel - Myokardinfarkt - Stentthrombose

platelet inhibition - acute coronary syndrome - PCI - ticagrelor - prasugrel - clopidogrel - myocardial infarction - stent thrombosis

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