Kernaussagen
Akutes Koronarsyndrom (ACS)
Neben der typischen Klinik ist das Ruhe-EKG zunächst wegweisend. Das akute Kornarsyndrom
ohne ST-Hebung wird vom akuten Koronarsyndrom mit ST-Hebung abgegrenzt. Die definitive
Diagnose eines Myokardinfarkts (mit oder ohne ST-Hebung) setzt den Nachweis einer
myokardialen Zellnekrose (Erhöhung von Troponin/CK) voraus.
ACS ohne ST-Strecken-Hebung
Beim ACS ohne ST-Hebung sind insbesondere Patienten mit ST-Senkung, Troponin-Erhöhung,
elektrischer oder hämodynamischer Instabilität gefährdet und sollten spätestens innherhalb
von 48 Stunden einer invasiven Diagnostik und ggf. Therapie zugeführt werden. Bereits
vorher ist unmittelbar nach Diagnosestellung eine antithrombotische Therapie mit ASS
und Clopidogrel sowie unfraktioniertem Heparin einzuleiten. GP-IIb/IIIa-Rezeptorantagonisten
und/oder Bivalirudin kommen vornehmlich im Herzkatheterlabor zum Einsatz.
ACS mit ST-Strecken-Hebung
Da die ST-Hebung auf einen akuten vollständigen Koronarverschluss hinweist, ist bei
diesen Patienten die rasche Reperfusionstherapie vordringlich. Ein Nutzen ist in der
Regel bis zur 12. Stunde nach Symptombeginn zu erwarten. Je früher die Reperfusion
erreicht wird, umso mehr Myokardgewebe kann gerettet werden. Als Therapie der ersten
Wahl gilt die direkte Katheterintervention (PCI). Nur bei mutmaßlich längerer Zeitverzögerung
bis zu einer möglichen Katheterintervention (mehr als 90 Minuten Zeitverlust im Vergleich
zur Einleitung einer Fibrinolysetherapie) sollte eine Fibrinolysetherapie als primäre
Reperfusionsmaßnahme erwogen werden. Nach Ausschluss von Kontraindikationen sollten
fibrinspezifische Bolus-Fibrinolytika bevorzugt werden. Insbesondere Patienten mit
kurzer Latenzzeit seit Symptombeginn (< 3 h) profitieren von der Fibrinolysetherapie.
Als Begleitmedikation ist für alle Patienten ASS und Clopidogrel und unfraktioniertes
Heparin von Nutzen, Abciximab zusätzlich im Rahmen der direkten PCI.
Literatur
- 1
Hamm C W. et al .
Leitlinien: Akutes Koronarsyndrom (ACS) Teil 1.
Z Kardiol.
2004;
93
72-90
- 2
Hamm C W. et al .
Leitlinien: Akutes Koronarsyndrom (ACS) Teil 2.
Z Kardiol.
2004;
93
324-341
- 3
Braunwald E.
Unstable angina. A classification.
Circulation.
1989;
80
410-414
- 4
Oler A, Whooley M A, Oler J, Grady D.
Adding heparin to aspirin reduces the incidence of myocardial infarction and death
in patients with unstable angina. A meta-analysis.
JAMA.
1996;
276
811-815
- 5
Antman E M, Cohen M, Radley D, McCabe C, Rush J, Premmereur J, Braunwald .
Assessment of the treatment effect of enoxaparin for unstable angina/non-Q-wave myocardial
infarction: TIMI 11B-ESSENCE meta-analysis.
Circulation.
1999;
100
1602-1608
- 6
Ferguson J J, Califf R M, Antman E M, Cohen M, Grines C L, Goodman S, Kereiakes D J,
Langer A, Mahaffey K W, Nessel C C et al for the SYNERGY Trial Investigators.
Enoxaparin vs. unfractionated heparin in high-risk patients with non-ST-segment elevation
acute coronary syndromes managed with an intended early invasive strategy: primary
results of the SYNERGY randomised trial.
Jama.
2004;
292
45-54
- 7
Silber S. et al .
Guidelines for Percutaneous Coronary Interventions (ESC).
Eur Heart J.
2005;
26
804-847
- 8
Bittl J A, Strony J, Brinker J A, Ahmed W H, Meckel C R, Chaitmann E, Maraganore J,
Deutsch E, Adelman B.
Treatment with bivalirudin(Hirulog) as compared with heparin during coronary angioplasty
for unstable or postinfarction angina. Hirulog Angioplasty Study Investigators.
N Engl J Med.
1995;
333
764-769
- 9
Lincoff A M, Bittl J A, Harrington R A, Feit F, Kleiman N S, Jackman J D, Sarembock I J,
Cohen D J et al for the REPLACE-2 Investigators.
Bivalirudin and provisional glycoprotein IIb/IIIa blockade compared with heparin and
planned glycoprotein IIb/IIIa blockade during percutaneous coronary intervention.
JAMA.
2003;
289
853-863
- 10
Antithrombotic Trial Collaboration .
Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention
of death, myocardial infarction, and stroke in high risk patients.
BMJ.
2002;
324
71-86
- 11
Yusuf S, Zaho F, Mehta S R, Chrolavicius S, Tognoni G, Fox K K.
Effects of Clopidogrel in addition to aspirin in patients with acute coronary syndromes
without ST-segment elevation.
N Engl J Med.
2001;
345
494-502
- 12
Boersma E, Harrington R, Moliterno D, White H, Theroux P, Van De Werf F, de Torbal A,
Piper K, Armstrong P, Wallentin L, Wilcox R, Simes J, Califf R M, Topol E J, Simoons M L.
Platelet glycoproteinIIb/IIIa inhibitors in acute coronary syndromes: A meta-analysis
of all major randomised clinical trials.
Lancet.
2002;
359
189-198
- 13
Kong D F, Hasselblad V, Harrington R A, White H D, Tchenkg J E, Kandzari D E, Topol E J,
Califf R M.
Meta-Analysis of survival with platelet glycoprotein IIb/IIIa antagonists for percutaneous
coronary interventions.
Am J Cardiol.
2003;
92
651-655
- 14
CAPTURE Investigators .
Randomised placebo-controlled trial of abciximab before und during coronary intervention
in refractory unstable angina: the CAPTURE Study.
Lancet.
1997;
349
1429-1435
- 15
EPIC investigators .
Use of a monoclonal antibody directed against the platelet glycoprotein IIb/IIIa receptor
in high-risk angioplasty.
N Engl J Med.
1994;
330
956-961
- 16
EPISTENT investigators .
Randomised placebo-controlled and balloon-angioplasty-controlled trial to assess safety
of coronary stenting with use of platelet glycoprotein-IIb/IIIa blockade. The EPISTENT
Investigators. Evaluation of Platelet IIb/IIIa Inhibitor for Stenting.
Lancet.
1998;
325
87-92
- 17
ESPRIT investigators .
Novel dosing regimen of eptifibatide in planned coronary stent implantation (ESPRIT):
a randomised, placebo-controlled trial.
Lancet.
2000;
356
2037-2044
- 18
O’Shea J C, Hafley G E, Greenberg S. et al .
Platelet glycoprotein IIb/IIIa blockade with eptifibatide in coronary stent intervention:
the ESPRIT trial: a randomized controlled trial.
JAMA.
2001;
285
2468-2473
- 19
Topol E J, Moliterno D J, Herrmann H C. et al .
Comparison of two platelet IIb/IIIa inhibitors, Tirofiban and abciximab, for the prevention
of ischemic events with percutaneous coronary revascularization.
N Engl J Med.
2001;
344
1888-1894
- 20
Moliterno D J, Yakubov S J, di Batiste P M, Herrmann H C, Stone G W, Macaya C, Neumann F J.
et al .
Outcomes at 6 months for the direct comparison of tirofiban and abciximab during percutaneous
coronary revascularisation with stent placement: the TARGET follow-up study.
Lancet.
2002;
360
355-360
- 21
Boden W E, O’Rourke R A, Crawford M H. et al .
Outcomes in patients with acute non-Q-wave myocardial infarction randomly assigned
to an invasive as compared with a conservative management strategy. Veterans Affairs
Non-Q-Wave Infarction Strategies in Hospital (VANQWISH) trial Investigators.
N Engl J Med.
1998;
338
1785-1792
- 22
TIMI IIIB-investigators .
Effects of tissue plasminogen activator and a comparison of early invasive and conservative
strategies in unstable angina and non-Q-wave myocardial infarction: results of the
TIMI IIIB trial. Thrombolysis In Myocardial Ischemia.
Circulation.
1994;
89
1545-1556
- 23
Fox K AA, Poole-Wilson P A, Henderson R A. et al .
Interventional versus conservative treatment for patients with unstable angina or
non-ST-elevation myocardial infarction: the British Heart Foundation RITA 3 randomised
trial.
Lancet.
2002;
360
743-751
- 24
FRISC II investigators .
Invasive compared with non-inasive treatment in unstable coronary-artery disease:
FRISC II prospective randomised multicentre study. Fragmin and Fast Revascularisation
during Instability in Coronary artery disease Investigators.
Lancet.
1999;
354
708-715
- 25
Cannon C P, Weintraub W S, Demopoulus L A et al for the TACTICS investigators.
Comparison of early invasive and conservative strategies in patients with unstable
coronary syndromes treated with the glycoproteinIIb/IIIa inhibitor tirofiban.
N Engl J Med.
2001;
344
1879-1887
- 26
Neumann F-J, Kastrati A, Pogatsa-Murray G, Behilli J, Bollwein H, Bestehorn H-P, Schmitt C,
Seyfarth M, Dirschinger J, Schömig A.
Evaluation of prolonged antithrombotic pretreatment („cooling-off” strategy) before
intervention in patients with unstable coronary syndromes.
JAMA.
2003;
290
1593-1599
- 27
Antman E M. et al .
ACC/AHA Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction.
J Am Coll Cardiol.
2004;
44
671-719
- 28
Fibrinolytic Therapy Trialists’ (FTT) Collaborative Group .
Indications for fibrinolytic therapy in suspected acute myocardial infarction: collaborative
overview of early mortality and major morbidity results from all randomised trials
of more than 1000 patients.
Lancet.
1994;
343
311-322
- 29
Boersma E, Maas A CP, Deckers J W. et al .
Early thrombolytic treatment in acute myocardial infarction: reappraisal of the golden
hour.
Lancet.
1996;
348
771-775
- 30
The GUSTO-Investigators .
An international randomized trial comparing four thrombolytic strategies for acute
myocardial infarction.
N Engl J Med.
1993;
329
673-682
- 31
Assessment of the safety and Efficacy of a New Thrombolytic Investigators .
Single-bolus tenecteplase compared with front-loaded alteplase in acute myocardial
infarction: The ASSENT-2 double-blind randomised trial.
Lancet.
1999;
354
716-722
- 32
Topol E J. The GUSTO V investigators .
Reperfusion therapy for acute myocardial infarction with fibrinolytic therapy or combination
reduced fibrinolytic therapy and platelet glycoprotein IIb/IIIa inhibition:the GUSTO
V randomized trial.
Lancet.
2001;
357
1905-1914
- 33
The Assessment of the safety and Efficacy of a New Thrombolytic Regimen (ASSENT)-3
investigators .
Efficacy and safety of tenecteplase in combination with enoxaparin, abciximab, or
unfractionated heparin: the ASSENT-3 randomised trial in acute myocardial infarction.
Lancet.
2001;
358
605-613
- 34
Keeley E C, Boura J A, Grines C L.
Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction:
a quantitative review of 23 randomised trials.
Lancet.
2003;
361
13-20
- 35
ISIS-2 (Second International Study of Infarct Survival) Collaborative Group .
Randomised trial of intravenous streptokinase, oral aspirin, both, or either among
17 187 cases of suspected acute myocardial infarction: ISIS-2.
Lancet.
1988;
0
349-360
- 36
Sabatine M S. et al .
CLARITY-TIMI 28 Investigators. Addition of Clopidogrel to Aspirin and fibrinolytic
therapy for myocardial infarction with ST-segment elevation.
N Engl J Med.
2005;
352
1179-1189
- 37
Freemantle N, Cleland J, Young P, Mason J, Harrison J.
Beta blockade after myocardial infarction: systemic review and meta regression analysis.
BMJ.
1999;
318
1730-1737
- 38
Flather M D, Yusuf S, Kober L. et al .
Long-term ACE-inhibitor therapy in patients with heart failure of left ventricular
dysfunction: a systematic overview of data from individual patients. ACE-Inhibitor
Myocardial Infarction Collaborative Group.
Lancet.
2000;
355
1575-1581
Prof. Dr. med. Hans-Jürgen Rupprecht
II. Medizinische Klinik · GPR-Klinikum
August-Bebel-Str. 59 · 65428 Rüsselsheim
eMail: hj.rupprecht@GP-Ruesselsheim.de
