Antikoagulation und Antidote

Angesichts des demografischen Wandels ist davon auszugehen, dass Rettungsdienstmitarbeiter und Notaufnahmeteams zunehmend Patienten behandeln werden, die sich einer Antikoagulationstherapie unterziehen. Dieser Artikel bietet einen Überblick über den aktuellen Stand der Entwicklung in der Prävention und Behandlung von Blutungskomplikationen bei Patienten unter oraler Antikoagulation.

Schlüsselwörter

Blutungskomplikationen - Blutgerinnung - DOAK - Thromboembolie - Vitamin-K-Antagonisten

• Literatur

• 1 Chen A, Stecker E, Warden BA. Direct oral anticoagulant use: a practical guide to common clinical challenges. J Am Heart Assoc 2020; 9: e017559
• 2 Mackman N, Tilley RE, Key NS. Role of the extrinsic pathway of blood coagulation in hemostasis and thrombosis. Arterioscler Thromb Vasc Biol 2007; 27: 1687-1693
• 3 Hoffman M, Monroe 3rd DM. A cell-based model of hemostasis. Thromb Haemost 2001; 85: 958-965
• 4 Ansell J, Hirsh J, Hylek E. et al. Pharmacology and management of the vitamin K antagonists: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; 133 (Suppl. 6) 160S-198S
• 5 Gage BF, Eby C, Johnson JA. et al. Use of pharmacogenetic and clinical factors to predict the therapeutic dose of warfarin. Clin Pharmacol Ther 2008; 84: 326-331
• 6 Wittkowsky AK, Devine EB. Frequency and causes of overanticoagulation and underanticoagulation in patients treated with warfarin. Pharmacotherapy 2004; 24: 1311-1316
• 7 Schmiedl S, Rottenkolber M, Szymanski J. et al. Blutungskomplikationen und Leberschädigungen unter Phenprocoumon. Dtsch Arztebl Int 2013; 110: 523-524
• 8 Connolly SJ, Ezekowitz MD, Yusuf S. et al. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med 2009; 361: 1139-1151
• 9 Van Gelder IC, Rienstra M, Bunting KV. et al. 2024 ESC Guidelines for the management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2024; 45: 3314-3414
• 10 Siegal DM, Curnutte JT, Connolly SJ. et al. Andexanet alfa for the reversal of factor Xa inhibitor activity. N Engl J Med 2015; 373: 2413-2424
• 11 Grottke O, Afshari A, Ahmed A. et al. Clinical guideline on reversal of direct oral anticoagulants in patients with life threatening bleeding. Eur J Anaesthesiol 2024; 41: 327-350
• 12 Pollack jr. CV, Reilly PA, Eikelboom J. et al. Idarucizumab for dabigatran reversal. N Engl J Med 2015; 373: 511-520
• 13 Sarode R, Milling jr. TJ, Refaai MA. et al. Efficacy and safety of a 4-factor prothrombin complex concentrate in patients on vitamin K antagonists presenting with major bleeding: a randomized, plasma-controlled, phase IIIb study. Circulation 2013; 128: 1234-1243
• 14 Heim MU. Die neuen Querschnitts–Leitlinien der Bundesärztekammer – Evidenz–basierte Empfehlungen für die Risiko–Nutzen–Abwägung bei der Hämotherapie. Anästhesiol Intensivmed Notfallmed Schmerzther 2009; 44: 186-199
• 15 Deutsche Gesellschaft für Neurologie e. V. (DGN). S2k-Leitlinie Behandlung von spontanen intrazerebralen Blutungen. Version 6.2. AWMF-Registernr.: 030–002. 01.04.2021 Accessed May 23, 2025 at: https://register.awmf.org/de/leitlinien/detail/030-002
• 16 Alban S. Antikoagulation. Das Gerinnungskompendium: Schnellorientierung, Befundinterpretation, klinische Konsequenzen. Stuttgart: Thieme; 2012
• 17 Gayet-Ageron A, Prieto-Merino D, Ker K. Antifibrinolytic Trials Collaboration. et al. Effect of treatment delay on the effectiveness and safety of antifibrinolytics in acute severe haemorrhage: a meta-analysis of individual patient-level data from 40 138 bleeding patients. Lancet 2018; 391: 125-132
• 18 Ageno W, Gallus AS, Wittkowsky A. et al. Oral anticoagulant therapy: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141 (Suppl. 2) e44S-e88S
• 19 Connolly SJ, Milling jr. TJ, Eikelboom JW. et al. Andexanet alfa for acute major bleeding associated with factor Xa inhibitors. N Engl J Med 2016; 375: 1131-1141
• 20 Connolly SJ, Sharma M, Cohen AT. et al. Andexanet for factor Xa inhibitor–associated acute intracerebral hemorrhage. N Engl J Med 2024; 390: 1745-1755
• 21 Orso D, Fonda F, Brussa A. et al. Andexanet alpha versus four-factor prothrombin complex concentrate in DOACs anticoagulation reversal: an updated systematic review and meta-analysis. Crit Care 2024; 28: 221
• 22 Pisters R, van Oostenbrugge RJ, Knottnerus IL. et al. The likelihood of decreasing strokes in atrial fibrillation patients by strict application of guidelines. Europace 2010; 12: 779-784
• 23 White K, Faruqi U, Cohen AAT. New agents for DOAC reversal: a practical management review. Br J Cardiol 2022; 29: 1
• 24 Aggarwal R, Ruff CT, Virdone S. et al. Development and validation of the DOAC Score: a novel bleeding risk prediction tool for patients with atrial fibrillation on direct-acting oral anticoagulants. Circulation 2023; 148: 936-946
• 25 January CT, Wann LS, Calkins H. et al. 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2019; 74: 104-132
• 26 Tomaselli GF, Mahaffey KW, Cuker A. et al. 2020 ACC Expert consensus decision pathway on management of bleeding in patients on oral anticoagulants: a report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol 2020; 76: 594-622
• 27 Ruff CT, Giugliano RP, Antman EM. Management of bleeding with non-vitamin k antagonist oral anticoagulants in the era of specific reversal agents. Circulation 2016; 134: 248-261
• 28 Pollack jr. CV, Reilly PA, Eikelboom J. et al. Idarucizumab for dabigatran reversal: updated results of the RE-VERSE AD study. Presented on 15 November at the American Heart Association (AHA) Scientific Sessions 2016. New Orleans, Louisiana 2016
• 29 Schlake A, Scheiermann P, Webwe CF. Was ist neu … bei den Faktor-XI-Inhibitoren: DOAK 2.0. Anaesthesiologie 2024; 73: 272-274
• 30 Zhao H, Coote S, Pesavento L. et al. Prehospital idarucizumab prior to intravenous thrombolysis in a mobile stroke unit. Int J Stroke 2018; 14: 265-269