Thrombozytenfunktionshemmer bei zerebralen Ischämien

M. G. Hennerici

doi:10.1055/s-0038-1660023

Hämostaseologie, Table of Contents

Hamostaseologie 1997; 17(02): 92-99
DOI: 10.1055/s-0038-1660023

Übersichtsarbeiten/Review Articles

Schattauer GmbH

Thrombozytenfunktionshemmer bei zerebralen Ischämien

M. G. Hennerici

¹Neurologische Universitätsklinik, Ruprecht-Karls-Universität Heidelberg, Klinikum Mannheim (Direktor: Prof. Dr. M. G. Hennerici)

› Author Affiliations

Abstract

Zusammenfassung

Azetylsalizylsäure (ASS) ist einer der bestuntersuchten Thrombozytenfunktionshemmer in der Primär- und Sekundärprävention zerebraler Insulte. Da unterschiedliche Strategien und Endvariablen in zahlreichen randomisierten, doppelblind-, z.T. plazebokontrollierten Studien verwandt wurden, waren Metaanalysen notwendig, um zu zeigen, daß ASS bei diesen Patienten eine Reduktion des Hirninfarktrezidivs (Sekundärprophylaxe) um 22% bewirkt. Ob eine solche Risikoreduktion allerdings tatsächlich erreicht wird, ist nach dem Ergebnis der einzelnen Studien fraglich: lange Zeit gab es nur eine einzige signifikante Untersuchung, bei der an einer allerdings nur sehr kleinen Patientenzahl gegenüber Plazebo eindeutig eine Risikoreduktion einer relativ hohen ASS-Dosierung in der Sekundärprävention gezeigt werden konnte. Wegen der Nebenwirkungen und der damit einhergehend schlechten Compliance werden weltweit überwiegend die niedrigen Dosierungen zur Sekundärprophylaxe empfohlen, ohne daß deren Effektivität bislang wissenschaftlich exakt wirklich nachgewiesen werden konnte. In der Primärprophylaxe gibt es für Thrombozytenaggregationshemmer keinen Wirksamkeitsnachweis, andere Substanzen, insbesondere Dipyridamol (DP) und Sulfinpyrazon haben in früheren Studien ebenfalls keinen Therapie-Effekt zeigen können. Die gerade veröffentlichte bislang größte Studie zu diesem Thema, ESPS 2, scheint nun eine Wirksamkeit von 50 mg ASS/Tag, DP allein (400 mg/Tag) und additiv in Kombination beider Substanzen zu belegen. Neueste Daten der gerade abgeschlossenen Clopidogrel-Studie ergeben anhand riesiger Fallzahlen (ca. 20.000 Patienten), daß Clopidogrel nebenwirkungsärmer als Ticlopidin und effektiver als ASS ist. Problematisch am Studiendesign aller Untersuchungen ist ihr Mangel, den unterschiedlichen Ursachen eines ischämischen Hirninsults nachzugehen und dies in die Auswahl der Studienmedikation einfließen zu lassen. Auch haben viele Studien es versäumt, das Risikoprofil der Patienten zu optimieren, die Interaktion mit Substanzen überlappender Wirksamkeit näher zu analysieren und alle Therapiemaßnahmen auch zu kontrollieren. Dies sollte in zukünftigen Studien beachtet werden.

Schlüsselwörter

Thrombozytenfunktionshemmer - Schlaganfallprophylaxe - zerebrale Ischämie

Full Text

References

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