Dauer der dualen antithrombozytären Therapie bei koronaren Risikopatienten^[*]

Abstract

Recent guidelines suggest a dual antiplatelet therapy after „drug-eluting“ stent (DES) implantation for 6 months in stable patients and for 12 months in patients after acute coronary syndrome (ACS). Serious complications after stent implantation include stent thrombosis, recurrent myocardial infarction, ischemic stroke, cardiovascular death and bleeding. These complications also occur beyond one year after coronary intervention. Thus, the question arises, whether a prolonged dual antiplatelet therapy ( > 12 months after PCI) is of benefit to lower thromboischemic events in high-risk patients. Recent randomized clinical studies (DAPT, ITALIC, OPTIDUAL and PEGASUS) have addressed this important clinical issue. The results of these studies are summarized and discussed.

Kernaussagen

• Derzeitige Leitlinien empfehlen eine duale antithrombozytäre Therapie für 6 – (12) Monate bei stabiler KHK und für 12 Monate bei ACS nach PCI.

• Eine Verlängerung der DAPT über die in den Leitlinien empfohlene Dauer hinaus ist nach den Ergebnissen großer randomisierter Studien nicht generell zu empfehlen.

• Eine verlängerte DAPT geht mit selteneren thromboischämischen Ereignissen einher, aber auch mit signifikant häufigeren schwerwiegenden Blutungen.

• Hochrisikopatienten wie Patienten mit Diabetes, Niereninsuffizienz oder einem Myokardinfarkt in der Anamnese, die ein hohes langfristiges Risiko für thromboischämische Ereignisse aufweisen, können von einer verlängerten DAPT über die derzeit empfohlene Dauer profitieren.

• Die aktuellen Leitlinien lassen die Möglichkeit offen, die DAPT in begründeten Einzelfällen – individuell für den Patienten – zu verlängern.

• Dabei sollte jedoch das individuelle Blutungsrisiko berücksichtigt und die Verlängerung bei Patienten angewendet werden, welche die DAPT initial ohne Blutungsereignisse vertragen haben.

^* Aktualisierte und erweiterte Fassung von Rath D, Gawaz M. Wie lange duale antithrombozytäre Therapie bei koronaren Risikopatienten? Aktuel Kardiol 2016; 5: 362 – 366.

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