Subscribe to RSS
DOI: 10.1055/s-2006-956261
© Georg Thieme Verlag KG Stuttgart · New York
Antithrombozytäre Therapie bei akutem Koronarsyndrom ohne ST-Strecken-Elevation
Antithrombotic treatment of acute coronary syndromes without ST-segment elevationPublication History
eingereicht: 14.6.2006
akzeptiert: 5.10.2006
Publication Date:
15 November 2006 (online)
Zusammenfassung
Für Patienten mit akutem Koronarsyndrom ohne ST-Strecken-Elevation, aber mit Risikomerkmalen (positiver Troponin-Status, Diabetes mellitus, signifikante ST-Streckensenkungen, hoher TIMI-Risikoscore) empfehlen die nationalen und internationalen Fachgesellschaften eine frühinvasive Vorgehensweise (rasche Herzkatheteruntersuchung) und eine effiziente antithrombozytäre Therapie. Letztere basiert neben der obligaten Gabe von Acetylsalicylsäure auf Thienopyridinen (Clopidogrel) sowie Glykoprotein-IIb/IIIa-Rezeptorantagonisten (GPIIb/IIIa-Rezeptorantagonisten). Die Initiierung einer antithrombozytären Therapie sollte bei Risikopatienten schon vor Durchführung einer invasiven Diagnostik beginnen. Dieses Vorgehen wird als „Upstream-Therapie” bezeichnet und in den nationalen sowie internationalen Leitlinien für die GPIIb/IIIa-Rezeptorantagonisten empfohlen. Der Zeitpunkt der Clopidogrel-Erstgabe ist bislang noch nicht prospektiv evaluiert worden. Post-hoc-Analysen zeigen jedoch auch für Clopidogrel einen Vorteil der Upstream-Therapie. Eine antithrombozytäre „Downstream-Therapie” (Initiierung der Medikamentengabe erst kurz vor oder während der invasiven Diagnostik) ist nach den aktuellen Leitlinien hinsichtlich der GPIIb/IIIa-Rezeptorantagonisten bei solchen Patienten zu bevorzugen, die einer sofortigen Herzkatheteruntersuchung bedürfen (< 2,5 h nach Symptombeginn).
Summary
National and international guidelines recommend an early invasive strategy (cardiac catheterization) and efficacious inhibition of platelet aggregation in patients with acute coronary syndrome (ACS) without ST-segment elevation but with risk factors (raised troponin level, diabetes mellitus, significant ST-segment depression, high TIMI risk score). Platelet inhibition includes the administration of aspirin, thienopyridines (i.e. clopidogrel) and GPIIb/IIIa receptor antagonists. In patients at risk antithrombotic treatment should be started before invasive diagnostic procedures ("upstream" treatment) including GPIIb/GPIIIa receptor antagonists. The timing of clopidogrel administration has not been studied prospectively so far, however, post-hoc analyses suggest beneficial effects of a clopidogrel "upstream" management. According to current guidelines "downstream" GPIIb/GPIIIa (initiation of antithrombotic medication just before or during invasive diagnostic catheterization) is preferred in those patients who require immediate cardiac catheterization (< 2 hours after onset of symptoms).
Literatur
- 1 Bertrand M E, Simoons M L, Fox K AA. et al . Management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 2002; 23 1809-1840
- 2 Bolognese L, Falsini G, Liistro F. et al . Randomized comparison of upstream tirofiban versus downstream high bolus dose tirofiban or abciximab on tissue-level perfusion and troponin release in high-risk acute coronary syndromes treated with percutaneous coronary interventions. J Am Coll Cardiol. 2006; 47 522-528
- 3 Braunwald E, Antman E M, Beasley J W. et al . The ACC/AHA 2002 guideline update for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2002; 40 1366-1374
- 4 Cannon C P, Weintraub W S, Demopoulos L A. et al . Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban. N Engl J Med. 2001; 344 1879-1887
- 5 Giugliano R P, Newby L K, Harrington R A. et al.; EARLY ACS Steering Committee . The early glycoprotein IIb/IIIa inhibition in non-ST-segment elevation acute coronary syndrome (EARLY ACS) trial: a randomized placebo-controlled trial evaluating the clinical benefits of early front-loaded eptifibatide in the treatment of patients with non-ST-segment elevation acute coronary syndrome - study design and rationale. Am Heart J. 2005; 149 994-1002
- 6 Glaser R, Glick H A, Herrmann H C, Kimmel S E. The role of risk stratification in the decision to provide upstream versus selective glycoprotein IIb/IIIa inhibitors for acute coronary syndromes. A cost-effectiveness analysis. J Am Coll Cardiol. 2005; 47 529-537
- 7 Hamm C W. Leitlinien: Akutes Koronarsyndrom (ACS) Teil 1: Akutes Koronarsyndrom ohne persistierende ST-Hebung. Z Kardiol. 2004; 93 72-90
- 8 Hamm C W. Leitlinien: Akutes Koronarsyndrom (ACS) Teil 2: Akutes Koronarsyndrom mit persistierender ST-Hebung. Z Kardiol. 2004; 93 324-341
- 9 Heusch G, Schulz R, Haude M, Erbel R. Coronary microembolisation. J Mol Cell Cardiol. 2004; 37 23-31
- 10 Kastrati A, Mehilli J, Neumann F J. et al.; Intracoronary Stenting and Antithrombotic Regimen Rapid Early Action for Coronary Treatment 2 (ISAR-REACT 2) Trial Investigators . Abciximab in patients with acute coronary syndromes undergoing percutaneous coronary intervention after clopidogrel pretreatment: the ISAR-REACT 2 randomized trial. JAMA. 2006; 295 1531-1538
- 11 Mahoney E M, Jurkovitz C T, Chu H. et al . Cost and cost-effectiveness of an early invasive vs conservative strategy for the treatment of unstable angina and non-ST-segment elevation myocardial infarction. JAMA. 2002; 288 1851-1858
- 12 Moliterno D J, Yakubov S J. et al.; TARGET investigators . 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
- 13 Neumann F J, Kastrati A, Pogatsa-Murray G. et al . Evaluation of prolonged antithrombotic pretreatment („cooling-off” strategy) before intervention in patients with unstable coronary syndromes: a randomized controlled trial. JAMA. 2003; 290 1593-1599
- 14 Roe M T, Parsons L S, Pollack C V. et al . Quality of care by classification of myocardial infarction: treatment patterns for ST-segment elevation vs non-ST-segment elevation myocardial infarction. Arch Intern Med. 2005; 165 1630-1636
- 15 Silber S, Albertsson P, Aviles F F. et al.; Task Force for Percutaneous Coronary Interventions of the European Society of Cardiology . Guidelines for percutaneous coronary interventions. Eur Heart J. 2005; 26 804-847
- 16 Smith S C, Feldman T E, Hirshfeld J W. et al. American College of Cardiology/American Heart Association Task Force on Practice Guidelines; ACC/AHA/SCAI Writing Committee to Update 2001 Guidelines for Percutaneous Coronary Intervention . ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2006; 113 e166-286
- 17 Steinhubl S R, Talley J D, Braden G A. et al . Point-of-care measured platelet inhibition correlates with a reduced risk of an adverse cardiac event after percutaneous coronary intervention. Results of the GOLD (AU-Assessing Ultegra) Multicenter Study. Circulation. 2001; 103 2572-2578
- 18 Steinhubl S R, Berger P B, Mann J T. et al.; CREDO Investigators . Clopidogrel for the Reduction of Events During Observation. Early and sustained dual oral antiplatelet therapy following percutaneous coronary intervention: a randomized controlled trial. JAMA. 2002; 288 2411-2420
- 19 The ESPRIT Investigators . Enhanced Suppression of the Platelet IIb/IIIa Receptor with Integrilin Therapy. Novel dosing regimen of eptifibatide in planned coronary stent implantation (ESPRIT): a randomised, placebo-controlled trial. Lancet. 2000; 356 2037-2044
- 20 The PRISM Study Investigators . A comparison of aspirin plus tirofiban with aspirin plus heparin for unstable angina. N Engl J Med. 1998; 338 1498-1505
- 21 The PRISM-PLUS Study Investigators . Inhibition of the platelet glycoprotein IIb/IIIa receptor with tirofiban in unstable angina and non-Q-wave-myocardial infarction. N Engl J Med. 1998; 338 1488-1497
- 22 The PURSUIT Investigators . Inhibition of platelet glycoprotein IIb/IIIa with eptifibatide in patients with acute coronary syndromes. The PURSUIT Trial Investigators. Platelet Glycoprotein IIb/IIIa in Unstable Angina Receptor Suppression Using Integrilin Therapy. N Engl J Med. 1998; 339 436-443
- 23 The RESTORE Investigators . Effects of platelet glycoprotein IIb/IIIa blockade with tirofiban on adverse cardiac events in patients with unstable angina or acute myocardial infarction undergoing coronary angioplasty. Circulation. 1997; 96 1445-1453
- 24 Valgimigli M, Percoco G, Barbieri D. et al . The additive value of tirofiban administered with the high-dose bolus in the prevention of ischemic complications during high-risk coronary angioplasty: the ADVANCE Trial. J Am Coll Cardiol. 2004; 44 14-19
- 25 de Winter R J, Windhausen F, Cornel J H. et al.; Invasive versus Conservative Treatment in Unstable Coronary Syndromes (ICTUS) Investigators . Early invasive versus selectively invasive management for acute coronary syndromes. N Engl J Med. 2005; 353 1095-1104
- 26 Yusuf S, Zhao F, Mehta S R. et al., Clopidogrel in Unstable Angina to Prevent Recurrent Events Trial Investigators . 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
Priv.-Doz. Dr. Peter W. Radke
Medizinische Klinik 2, Universitätsklinikum Schleswig-Holstein Campus Lübeck
Ratzeburger Allee 160
23538 Lübeck
Email: radke@innere2.uni-luebeck.de