Zusammenfassung
Die strukturierte Sekundärprävention ist eine wesentliche Voraussetzung für eine erfolgreiche
Schlaganfallvermeidung in der Zukunft. Die einzelnen Bereiche müssen konsequent behandelt
werden. Wesentlicher Risikofaktor ist der Bluthochdruck. Hier wurde gezeigt, dass
eine Blutdruckbehandlung nach einem Schlaganfall eine langfristige Reduktion der Letalität
von 10 % (über 5 Jahre) bewirkt. Außerdem konnte durch eine Metaanalyse an fast 1
Mio. Patienten gezeigt werden, dass sowohl in der primär- wie auch sekundärpräventiven
Situation die konsequente Blutdruckeinstellung das Schlaganfallrisiko um rund 40 %
senkt. Je stärker die Blutdrucksenkung, je stärker der präventive Effekt. Die vermeintliche
relevante Interaktion von Protonenpumpenhemmern und Clopidogrel, bei der der antiaggregatorische
Effekt von Clopidogrel abgeschwächt werden sollte, scheint zwar pharmakologisch relevant,
aber klinisch keine Rolle zu spielen. Beide Substanzgruppen können derzeit ohne Einschränkung
kombiniert werden. Patienten mit Vorhofflimmern und zerebrovaskulärem Ereignis sollten
wenn irgend möglich oral antikoaguliert werden. Bei Kontraindikation hat die Kombination
von ASS und Clopidogrel einen leichten Vorteil (deutliche Risikoreduktion bei erhöhtem
Blutungsrisiko) gegenüber ASS alleine und kann in Betracht gezogen werden. Dabigatran
als oraler direkter Thrombinantagonist hat gegenüber Vit.-K-Antagonisten den Vorteil
der sofortigen Wirksamkeit und fehlenden Notwendigkeit der Gerinnungskontrollen. Nach
der RELY-Studie scheint es bei gleicher Wirksamkeit in der niedrigeren Dosis sicherer
und bei gleicher Sicherheit in der höheren Dosis wirksamer als Vit.-K-Antagonisten
zu sein. Die Marktzulassung sollte in 2010 erfolgen. Statine wirken bis zu 10 Jahre
nach einem zerebrovaskulären Ereignis sekundärpräventiv. Die Operation einer Karotisstenose
scheint der Stentversorgung nach den Ergebnissen der Internationalen Carotid Stenosis
Stenting Study überlegen zu sein. Das Risiko eines Rezidivschlaganfalls bei dem Vorliegen
eines PFO ist mit einer OR von 1,1 sehr niedrig und sollte nicht Anlass zu invasiveren
Maßnahmen geben.
Abstract
Organised secondary prevention is a prerequisite for successful stroke therapy. One
of the most relevant factors is elevated blood pressure. It has been shown that long-term
blood pressure treatment leads to a significant reduction in mortality of almost 10
% over a 5-year period. Additionally, a large meta-analysis in almost 1 million patients
confirmed that blood pressure reduction leads to a constant reduction in secondary
cerebrovascular events by 40 %, both in primary and secondary prevention. The preventive
effect was stronger as the blood pressure reduction increased. Interactions between
proton-pump inhibitors and the antiplatelet agent clopidogrel did not receive scientific
confirmation. There is no reason to avoid this combination. Patients suffering from
atrial fibrillation and stroke should, whenever possible, be treated by oral anticoagulation.
In cases in which this treatment is abandoned, the combination of aspirin and clopidogrel
offers some marginal benefits over aspirin alone (higher stroke risk reduction, but
increase in brain haemorrhages). Dabigatran is a new direct oral thrombin antagonist.
It has the advantage compared to the oral vitamin K antagonists that it acts immediately
after intake and does not need further regular coagulation test controls. The huge
RELY study revealed that dabigatran is safer with the same efficacy in the lower dose,
but more effective with the same safety in the higher dose, compared to oral vitamin
K antagonists. It will be licensed in 2010. Statins seem to be beneficial for as long
as 10 years after a cerebrovascular accident. Carotid stenosis treatment seems to
be better done by operation as revealed by the International Carotid Stenosis Stenting
study. A patent foramen ovale is a slight risk factor with an OR of 1.1. Therefore,
any aggressive treatment options in patients with stroke and pfo seem to be unjustified.
Schlüsselwörter
Schlaganfall - Sekundärprävention - Blutdruck
Keywords
stroke - secondary prevention - blood pressure
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Prof. Dr. Gerhard F. Hamann
Neurologische Klinik, Dr. Horst Schmidt Klinik GmbH
Ludwig-Erhard-Str. 100
65199 Wiesbaden
Email: gerhard.hamann@hsk-wiesbaden.de
